Rick Le Concierge Services – Intake & Agreement

Rick Le Concierge Services – Intake & Agreement

This form gathers essential information to prepare your service—whether you’ve booked a Concierge Check-In, Lifestyle Check-In, or another personalized visit.The details you provide remain confidential and ensure we deliver support tailored to your needs with care, respect, and professionalism.
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Preferred follow‑up method

CallTextE-mailNo follow-up needed right now
MonthDayYear
Date
Hour MinutesAM/PM Option
Preferred Date & Time for Visit (optional)*

MonthDayYear
Date
What’s the main reason you’re requesting this visit?*
Anything we should know to support your mobility or access needs?*
City & Zip Code of Residence*

Street Address

Street Address Line 2

City

Zip Code
What type of support are you looking for today?

I’d like to learn more about your servicesConcierge Check-inLifestyle Check-in
Do you or someone you care for need help with any of the following?

Support with mobility or movement around the homeWeekly household tasks or wellness check-insTransportation to doctor or therapy appointmentsOther (please describe below)
Who is this for?

MyselfA family member or friendA client or neighbor
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