How to use this document

1Fill in your name, credential, phone, and email at the top — it auto-saves for next time.

2Complete one agreement per client. Fill in their name, address, and all terms you discussed at the meet-and-greet.

3Click "Print / Save PDF" — print two copies, sign both, keep one, give one to the client.

4Do not start a shift without a signed copy in your records.

Phone

Private Care Service Agreement

Agreement Date:

1. Parties

Caregiver

Full name & credential

Phone

Client

Client full name

Client address

Primary Family Contact

Name & relationship

Phone

3. Schedule

Start Date:

Regular Care Days

Hours: to Minimum per visit:

Schedule notes (live-in, rotating, on-call, etc.)

4. Rate & Payment

Hourly Rate: per hour

Payment Frequency:

Accepted payment methods:

Payment due within days of invoice.

A late fee of will be applied after days past due.

5. Cancellation Policy

Client cancellations require hours advance notice.

Cancellations with less than hours notice: a minimum of hours will be charged.

The Caregiver will provide hours notice when a shift cancellation is necessary.

6. Scope Limitations

The Caregiver will not perform skilled nursing procedures, including but not limited to: wound care, IV administration, injections, catheter care, tube feedings, or medical diagnosis. Care is limited to the personal care services listed in Section 2. If the client's care needs change beyond the scope of this agreement, both parties agree to revisit and update the terms before additional services are provided.

7. Terms & Termination

Either party may terminate this agreement with days written notice.

Immediate termination may occur in cases of abuse, neglect, unsafe working conditions, or non-payment. This is a private care agreement between two parties and does not constitute an employment arrangement with a staffing agency.

8. Agreement & Signatures

By signing below, both parties confirm they have read, understood, and agreed to the terms of this Private Care Service Agreement.

Caregiver Signature

Date

Client or Authorized Family Member Signature

Printed name

Relationship to client

Date