# 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.

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.

Canonical: https://reuily.com/templates/home-care-service-agreement
Use this template: https://reuily.com/form/from-template/home-care-service-agreement
Collections: Agreements & Waivers, Professional Services, Home & Senior Care
Last updated: 2026-10-24

## Questions

- Question 1: What's your full name? (Short Text, required)
- Question 2: What's your email address? (Email, required)
- Question 3: What's your phone number? (Phone, required)
- Question 4: Who are you signing for? (Single Choice, required). Options: Myself; A parent or family member; Someone I'm the legal representative for
- Question 5: If care is for someone else, what's their full name? (Short Text, optional)
- Question 6: Where will care take place? (Short Text, required)
- Question 7: Which services do you need? (Multiple Choice, required). Options: Companionship; Personal care; Meal preparation; Light housekeeping; Medication reminders; Transportation and errands; Respite care; Overnight care
- Question 8: How many hours of care a week? (Single Choice, required). Options: Under 10 hours; 10 to 20 hours; 20 to 40 hours; Live in or 24 hour care
- Question 9: When should care start? (Date, required)
- Question 10: Who is the emergency contact? (Short Text, required)
- Question 11: Anything our caregivers should know? (Long Text, optional)
- Agreement: Home care service agreement, accepted with "I agree" (full text below)
- Question 12: Sign the home care service agreement (Signature, required)

Signing records the signer's consent, email, IP address, browser and signing time, and each signer can download a signed PDF copy.

## Home care service agreement

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.

1. **Services.** The Agency provides the non medical services chosen above. Caregivers do not give medical treatment or manage medication beyond reminders.
2. **Rates.** The client pays **[hourly rate]** per hour, with a minimum of **[number]** hours per visit. Holidays are billed at **[holiday rate]**.
3. **Billing.** The Agency invoices **[weekly or every 2 weeks]**, and payment is due within **[number]** days.
4. **Schedule changes.** Visits cancelled with less than **[number]** hours notice are billed in full.
5. **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.
6. **Emergencies.** In an emergency the caregiver calls 911 first, then the emergency contact above.
7. **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.

## 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

## 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.