PERSONAL CARE AGREEMENT

This Agreement is made by and between the following parties:

Elder/Adult with disabilities_____________________________________________

And Caregiver ___________________________________________________________

DATE _____________________

Terms of Agreement

This Agreement shall commence on (date)_________________________, and may be terminated by either party on reasonable notice to the other party.

Purpose

The purpose of this Agreement is to set forth the terms and conditions under which CAREGIVER will assist ELDER/ADULT WITH DISABILITES with instrumental activities of daily living and/or activities of daily living in order for ELDER/ADULT WITH DISABILITIES to continue to live at home.

Services to be Performed

CAREGIVER will provide care to ELDER/ADULT WITH DISABILITIES in

____________________________________________ (Specify location, i.e. Home of the ELDER/ADULT WITH DISABILITIES, or CAREGIVER’S own home, or OTHER)

Services to be provided by CAREGIVER will include, but shall not necessarily be limited to: Check all that apply and provide detailed information about the services to be performed to meet the specific needs of the Elder/Adult with Disabilities.

Transportation and errands:

___Driving ELDER/ADULT WITH DISABILITIES to medical, dental, adult day care and other appointments and activities;

___Shopping for groceries and other items needed by ELDER/ADULT WITH DISABILITIES, and filling/refilling prescriptions;

___Running other errands for ELDER/ADULT WITH DISABILITIES.

__________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________

Meals:

Preparing 2-3 meals per day and daily snacks for ELDER/ADULT WITH DISABILITIES. __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________

Housework:

___ Cleaning ELDER ’s/ADULT WITH DISABILITIES’ living area.

___ Laundry and changing linens:

Financial:

___ Paying ELDER’s/ADULT WITH DISABILITIES’ bills, balancing Elder’s/Adult with Disabilities’ checkbook, making deposits, dealing with health insurance, other paperwork.

___ Administration of medication:

__________________________________________________________________ __________________________________________________________________ __________________________________________________________________

Assistance with the following activities of daily living:

• _____Transferring from bed, chair and toilet; ambulation; bathing, hygiene/ grooming; toileting; eating.
• _____Cueing ELDER/ADULT WITH DISABILITIES as to when to dress, eat, get up, go to bed and attend scheduled appointments.
• _____Monitoring the ELDER/ADULT WITH DISABILITIES for safety, including responding to alarm system to control wandering/ fall risk.
• _____Monitoring the ELDER/ADULT WITH DISABILITIES health, and bringing health problems to attention of health care providers.

Schedule

CAREGIVER will provide services on the following schedule:

Compensation

1. ELDER shall pay CAREGIVER $______ per Check One:

_______HOUR or ________DAY  or _________MONTH

1. TO BE USED IF ELDER LIVES IN CAREGIVER’S HOME: In addition, ELDER/ADULT WITH DISABILITIES shall pay CAREGIVER $_____________ per month for room and board (which consists of a proportional share of mortgage, taxes, insurance, heat, electricity, water, sewer and groceries).
2. ELDER/ADULT WITH DISABILITIES shall reimburse CAREGIVER for all out of pocket expenses borne by CAREGIVER in connection with CAREGIVER’S work. Such expenses shall include mileage at the rate of $__________ cents per mile.

ON BEHALF OF ELDER/ADULT WITH DISABILITIES:

__________________________________________________ Date:__________
[To be signed by Elder/Adult with Disabilities or by a legal representative for Elder/Adult with Disabilities such as agent under POA, guardian or conservator]

CAREGIVER:

__________________________________________________ Date:_________

Published by KaGardn1

I'm trying to live the most meaningful and intentional life possible. Minimalist, Vegetarian, Fierce protector of a full night sleep, Mother, Wife, Daughter -caretaker, Sister, Friend, Nurse. Sharing day to day life with family and friends. A quest to minimize effects of Alzheimer's Disease. View all posts by KaGardn1