Start Intake - Prime Care Life

If this is an emergency, please don't wait for us.

If someone is in immediate danger, call 911. For thoughts of suicide, self-harm, or emotional crisis, call or text 988 — the Suicide & Crisis Lifeline, available 24/7.

Progress Step 1 of 9

Identity

Minor

Request

Contact

Payment

Situation

Safety

Referral

Consent

Website

Step 1 of 9

Who are these services for?

Start by telling us about the person who will be receiving services. If you're filling this out for someone else, we'll get your info in a later step.

First name*

Please enter a first name.

Last name*

Please enter a last name.

Date of birth*

Please enter a date of birth.

Gender*

Please select an option.

Race / ethnicity(optional)

Primary language*

Please select a language.

Home address

Street address*

Please enter a street address.

City*

Please enter a city.

County*

Please enter a county.

ZIP*

Enter a 5-digit ZIP.

Phone*

Please enter a phone number.

Email*

Please enter a valid email.

Step 2 of 9

About the child.

Since services are for a minor, we need a bit more information about their family, school, and situation.

Parent or legal guardian name(s)*

Please enter the guardian's name.

Guardian relationship*

Please select an option.

Guardian phone*

Please enter the guardian's phone.

Child's school(optional)

Grade(optional)

Does the child have an IEP, 504 Plan, or behavioral plan?

Yes No Not sure

Is there an active DCF case?

Yes No

Step 3 of 9

Who are we helping?

A few quick questions about who this is for and who we'll be talking with.

Who is this intake for?*

Myself My child or a minor in my care An adult family member or loved one A client I'm referring as a professional

Please select who this intake is for.

Referring professional details

Your name*

Please enter your name.

Your role*

Please enter your role.

Agency / organization*

Please enter your agency.

Your phone*

Please enter your phone.

Your email*

Please enter your email.

Who's filling out this form?*

The client (myself) Parent or legal guardian Another family member Referring professional

Please select an option.

Your information (person filling this out)

Your name*

Please enter your name.

Relationship to client*

Please describe the relationship.

Your phone*

Please enter your phone.

What brings you to Prime Care Life? (select all that apply)*

Mental health support Getting connected to counseling, therapy, or psychiatry Housing assistance or housing-related resources SSI, disability, or benefits assistance Food assistance, transportation, childcare, or other basic needs Employment or education resources Medical care coordination Services for a child facing abuse, neglect, or a family crisis School support (IEP, 504, behavioral plan) Help navigating multiple systems / general case management Crisis Not sure yet — I need help figuring out what fits

Please select at least one reason.

Step 4 of 9

How can we reach you?

Tell us how you'd prefer to be contacted.

Emergency contact

Name*

Please enter a name.

Relationship*

Please enter a relationship.

Phone*

Please enter a phone.

Best way to reach the client*

Phone call Text message Email

Please select an option.

OK to leave a voicemail?*

Yes No

Please select an option.

Preferred appointment method*

In-home visit Virtual (video call) Phone call

Please select at least one.

Preferred days and times(optional)

Step 5 of 9

How will services be paid?

Most people we work with pay nothing out of pocket. If you're not sure, that's OK — we'll help figure it out.

Coverage type*

Florida Medicaid Private insurance Self-pay I need help figuring this out

Please select an option.

Medicaid details

Managed care plan(if known)

Medicaid ID number(if known)

Private insurance details

Carrier*

Please enter the carrier.

Member ID*

Please enter the member ID.

Group number(if listed)

Cardholder name*

Please enter the cardholder name.

Cardholder date of birth*

Please enter the cardholder DOB.

Step 6 of 9

Tell us what's going on.

In your own words. Skip the details you're not comfortable sharing here — we'll go deeper in person.

What's happening that made you reach out today?*

You can share as much or as little as you want. We'll go deeper when we talk.

Please share a bit about what's going on.

How urgent does this feel?*

This is a crisis right now Needs to happen soon, within a week or two We're planning ahead, no rush

Please select an option.

Step 7 of 9

A few important questions.

These help us make sure you get the right support right away.

Are you or the client currently having thoughts of self-harm or suicide?*

Yes No Prefer to discuss on the phone

Please select an option.

Are you or the client in immediate danger?*

Yes No

Please select an option.

What you shared tells us something urgent is happening.

If someone is in immediate danger, call 911. For thoughts of suicide, self-harm, or emotional crisis, call or text 988 — available 24/7.

Please reach out to one of these now. When you're safe, you can come back and finish this form. Or call our office at (321) 502-9445 during business hours to talk with a member of our team.

Step 8 of 9

How did you hear about Prime Care Life?

Almost done. This just helps us understand where people find us.

Referral source*

Online search Social media A doctor or hospital A school or teacher DCF A friend or family member Other

Please select an option.

Referral details

Name of person who referred you(optional)

Organization(optional)

Step 9 of 9

One last step.

Review, sign, and send. We'll respond within one business day — usually the same day.

I give Prime Care Life permission to contact me at the phone number and email I've provided — by call, voicemail, text, or email — about this intake request. Text messages may incur standard message and data rates from your carrier. I can change or withdraw this permission at any time by contacting Prime Care Life.*

Please check the box to continue.

OK to leave a detailed voicemail if I don't answer. Uncheck this if you'd prefer we leave a brief callback message only.

Signature (type your full name)*

Please type your full name.

Date