Home Care Service Agreement Template
A free home care service agreement for non medical home care agencies. Clients or family pick services and hours, read your terms, and sign online.
Customize the pages and design to fit your needs.
About this template
A home care service agreement with ready terms for rates, minimum visits, schedule changes, caregivers and notice. The client or a family member picks the services, hours and start date, then signs, and you keep a signed PDF.
Common uses
- Non medical home care agencies
- Companion and respite care
- Families arranging care for a parent
Key features
- Services and hours
- Rates, billing and notice terms
- Signed PDF for every client
What this template asks
What's your full name?
Short Text
What's your email address?
Email
What's your phone number?
Phone
Who are you signing for?
Single Choice · Myself, A parent or family member, Someone I'm the legal representative for
If care is for someone else, what's their full name?
Short Text · Optional
Where will care take place?
Short Text
Which services do you need?
Multiple Choice · Companionship, Personal care, Meal preparation, Light housekeeping, Medication reminders, Transportation and errands, Respite care, Overnight care
How many hours of care a week?
Single Choice · Under 10 hours, 10 to 20 hours, 20 to 40 hours, Live in or 24 hour care
When should care start?
Date
Who is the emergency contact?
Short Text
Anything our caregivers should know?
Long Text · Optional
Home care service agreement
Agreement text, accepted with “I agree”
Sign the home care service agreement
Signature
How to use this template
Copy it
Select Use template and a copy opens in your workspace as an unpublished draft.
Make it yours
Edit any question or answer, choose a theme, and add your logo.
Share it
Publish, then send the link, show a QR code, or embed the form on your site. Responses arrive in Submissions.
Home care service agreement
Signers read this text in the form before they accept it. Edit the bracketed details to match your business, and have the wording reviewed for your situation.
Please read this before you sign.
This agreement is between [Agency name] (the "Agency") and the client named in this form, or the person signing for them.
- Services. The Agency provides the non medical services chosen above. Caregivers do not give medical treatment or manage medication beyond reminders.
- Rates. The client pays [hourly rate] per hour, with a minimum of [number] hours per visit. Holidays are billed at [holiday rate].
- Billing. The Agency invoices [weekly or every 2 weeks], and payment is due within [number] days.
- Schedule changes. Visits cancelled with less than [number] hours notice are billed in full.
- Caregivers. The Agency screens, assigns and supervises caregivers and sends a replacement if the usual caregiver is away. The client does not hire an Agency caregiver directly for [number] months after their last visit.
- Emergencies. In an emergency the caregiver calls 911 first, then the emergency contact above.
- Ending. Either side may end this agreement with [number] days written notice.
By signing below, I confirm that I have read this agreement and agree to it.
Frequently asked questions
What should a home care service agreement include?
Services, rates, minimum visit hours, billing, schedule changes, caregiver assignment, emergencies and notice. This template covers each of them.
Can a family member sign for the client?
Yes. The signer says who they are signing for, so an adult child or legal representative can complete it.
Is it for medical home health care?
No. It's for non medical home care such as companionship and personal care. Licensed home health agencies need their own forms.