Caregiver Contract

Where will the caregiving take place?

At the patient's home

At an assisted living facility

Other

Enter the location

Is the caregiver an independent contractor?

Is the caregiver an independent contractor? YesNo, the caregiver is a salaried employee of the patient.

The caregiver will be required to work

The caregiver will be required to work On an "as-needed" basisA fixed number of hours per week

How many hours per week?

hours

Will the caregiver be required to follow a weekly schedule?

Will the caregiver be required to follow a weekly schedule? YesNo

The caregiver will be required to work

The caregiver will be required to work MondayTuesdayWednesdayThursdayFridaySaturdaySunday

Monday hours

Tuesday hours

Wednesday hours

Thursday hours

Friday hours

Saturday hours

Sunday hours

How much will the caregiver be paid?

The caregiver's duties will include:

The caregiver's duties will include: Preparing mealsAdministering medicationBathroom assistanceHouse cleaningTransportationFinancial tasksEveryday errands (e.g. making appointments, getting groceries, etc.)Other

Other:

Meal preparation will include

Meal preparation will include BreakfastLunchDinnerSnacks

House cleaning will include

House cleaning will include DishesLaundryVacuumingOther

Other

Financial tasks will include

Financial tasks will include Paying billsDepositing moneyPlacing ordersOther

Note: For certain financial tasks, the patient may be required to authorize a Durable Power of Attorney Form.

Other

Will the caregiver be provided with room and board?

Will the caregiver be provided with room and board? YesNo

The patient will provide the caregiver housing by

The patient will provide the caregiver housing by Providing a room in the patient's homeOffer money every month to cover the caregiver's rentOther

Other

Enter amount

$per month

Will the caregiver be provided with a vehicle?

Will the caregiver be provided with a vehicle? YesNo

Will the caregiver be offered to join any retirement plans?

Will the caregiver be offered to join any retirement plans? YesNo

e.g. 401K, IRA, health savings account

Select all that apply:

Select all that apply: 401(k)IRAHealth Savings AccountOther

Other

How many vacation days will the caregiver have?

days per year

Will the caregiver be entitled to personal leave?

Will the caregiver be entitled to personal leave? YesNo

For health, personal or family related matters.

How many days?

days per year

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

Which federal holidays will the caregiver be required to work?

Will the caregiver be provided with health insurance?

Will the caregiver be provided with health insurance? YesNo

What kind of coverage will be offered?

What kind of coverage will be offered? A full health insurance planPartial payment to a qualified provider

How much will be offered?

$per month

The probationary period shall last for

Days

The probationary period is the initial period when the Caregiver begins work and does not allow them 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.

Do you want to include any additional terms or conditions?

Do you want to include any additional terms or conditions? YesNo

Additional terms or conditions:

What is the caregiver's name?

What is the patient's name?

Which state do you live in?

Effective date

Save and finish later