A caregiver agreement is a contract between a patient and a person that is hired to "take care" of the patient. Patient's Name Full Name Caregiver's Name Caregiver's Name Full Name The Caregiver is an The Caregiver is an Employee (of the Patient)Independent Contractor Required for tax purposes. Payment Caregiver's Pay $ Per Per HourWeekBi-WeekMonthYear Housing Will the Patient be offering the Caregiver housing? Will the Patient be offering the Caregiver housing? YesNo For example, if the Caregiver is going to be living with the patient. The Patient offers to The Patient offers to Provide housing to the Caregiver by allowing them to live together.Offer money every month to take care of RentOther Enter Amount $per Month Write (other) Schedule Caregiver will be required to work Caregiver will be required to work On an "As-Needed" BasisFixed Number (#) of Hours per Week How many Hours will the Caregiver be required to work per week? Hours Minimum Number (#) Work Schedule Will the Caregiver be required to follow a Weekly Schedule? Will the Caregiver be required to follow a Weekly Schedule? YesNo A schedule of hours to be worked on a weekly basis. The Caregiver will be required to work: The Caregiver will be required to work: MondayTuesdayWednesdayThursdayFridaySaturdaySunday Monday Start Time A.M.P.M. End Time A.M.P.M. Tuesday Start Time A.M.P.M. End Time A.M.P.M. Wednesday Start Time A.M.P.M. End Time A.M.P.M. Thursday Start Time A.M.P.M. End Time A.M.P.M. Friday Start Time A.M.P.M. End Time A.M.P.M. Saturday Start Time A.M.P.M. End Time A.M.P.M. Sunday Start Time A.M.P.M. End Time A.M.P.M. Location The Caregiver will be taking care of the Patient at _____________________ The Caregiver will be taking care of the Patient at _____________________ the Patient's homethe Patient's assisted living facilityOther Where will the Caregiver be taking care of the Patient? Vehicle Will the Caregiver be provided with a Vehicle? Will the Caregiver be provided with a Vehicle? YesNo Transportation Will the Caregiver be required to bring the Patient to appointments or perform errands? Will the Caregiver be required to bring the Patient to appointments or perform errands? YesNo Meals Will the Caregiver be required to prepare meals for the Patient? Will the Caregiver be required to prepare meals for the Patient? YesNo How many meals per day? How many meals per day? 3 Meals2 Meals1 Meal Cleaning Will the Caregiver be required to clean? Will the Caregiver be required to clean? YesNo Select the Caregiver's responsibilities (check all that apply) Select the Caregiver's responsibilities (check all that apply) House CleaningDishesLaundryOther Other Financial Decisions Will the Caregiver be required to make financial decisions for the Patient? Will the Caregiver be required to make financial decisions for the Patient? YesNo Such as paying bills, changing plans (such as cable or internet, etc.), or any other type of financial task. Select which financial acts may be required: (check all that apply) Select which financial acts may be required: (check all that apply) Writing Checks (paying bills)Depositing MoneyMailing ItemsOther If any of the selections are made, most likely, the Patient and Caregiver will be required to authorize a Durable Power of Attorney Form. Other Medication Is the Caregiver responsible for the Patient to take their Medication correctly? Is the Caregiver responsible for the Patient to take their Medication correctly? YesNo Everyday Life Will the Caregiver be responsible for helping the Patient with everyday life? Will the Caregiver be responsible for helping the Patient with everyday life? YesNo Such as transferring the Patient from the bed, chair, or toilet. Select the Caregiver's responsibilities: (check applicable) Select the Caregiver's responsibilities: (check applicable) Transferring the Patient (to the chair, bed, or toilet)Schedule Tasks and Making AppointmentsMonitoring the PatientOther Other Residency The Patient is a resident of which State? Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWisconsinWyoming This is usually the State on the Patient's Drivers License. Retirement Plans Will the Caregiver be offered access to join any Retirement Plans? Will the Caregiver be offered access to join any Retirement Plans? YesNo Choose which Retirement Plans Choose which Retirement Plans 401(k)IRAHealth Savings AccountOther Other Vacation Time How many Vacation Days will the Caregiver have? Days per Year Personal Leave For health, personal or family related matters. Will the Caregiver be entitled to Personal Leave? Will the Caregiver be entitled to Personal Leave? YesNo How many days? Days per Year Holidays Will the Caregiver be required to work on Federal Holidays? Will the Caregiver be required to work on Federal Holidays? Yes, ALL Federal HolidaysYes, SOME Federal HolidaysNo Federal Holidays are: New Year's Day;Martin Luther King, Jr. Day;George Washington’s Birthday;Memorial Day;Independence Day;Labor Day;Columbus Day;Veterans Day;Thanksgiving Day; andChristmas Day. Name the Federal Holidays the Caregiver will HAVE TO work on: Health Insurance Will the Caregiver be obtaining Health Insurance as part of employment? Will the Caregiver be obtaining Health Insurance as part of employment? YesNo Either partially or in-full.. What kind of Health Insurance coverage? What kind of Health Insurance coverage? Full Health Insurance PlanPartial Payment How much $per Month Probationary Period The Probationary Period shall last for Days The Probationary Period is the initial period when the Caregiver begins work and does not allow he or she to obtain Benefits such as Vacation Time or Severance until a specified time-frame is completed. The typical Probationary Period is anywhere from 90 to 180 days. Additional Terms and Conditions Are there any Additional Terms or Conditions? Are there any Additional Terms or Conditions? YesNo This is your last chance to include anything that was not mentioned in this Agreement. Additional Terms and Conditions Effective Date Effective Date Next Save Save and finish later
