1. Client Information

Client Details

  • Client Name: [Client’s Full Name]
  • Date of Birth: [Client’s DOB]
  • Address: [Client’s Address]
  • Emergency Contact: [Emergency Contact Name and Phone]

2. Services and Responsibilities

Care Services

  • The senior care services provided will include:
    • [List of Specific Services, e.g., personal care, medication management, companionship]
    • [Any Additional Services]

Schedule and Fees

  • The agreed-upon schedule for care services is:
    • [Days and Hours]
  • The fees for services are as follows:
    • [Hourly Rate or Flat Fee]
    • [Billing Frequency, e.g., weekly, monthly]

Expectations and Responsibilities

  • The caregiver agrees to:

    • Provide compassionate and professional care.
    • Follow the care plan and instructions provided.
    • Maintain client confidentiality.
    • Report any changes in the client’s condition promptly.
  • The client (or guardian) agrees to:

    • Provide accurate health information.
    • Communicate preferences and needs clearly.
    • Pay fees promptly.
    • Treat the caregiver with respect.

3. Liability Waiver and Confidentiality

Liability Waiver

  • The client acknowledges that senior care involves inherent risks.
  • The caregiver is not liable for any injuries or accidents during the course of care.


  • The caregiver agrees to keep all client information confidential.
  • Personal and medical details will not be disclosed without consent.

4. Termination and Dispute Resolution


  • Either party may terminate this agreement with [Notice Period] written notice.
  • Termination may occur due to non-payment, violation of terms, or other valid reasons.

Dispute Resolution

  • Any disputes will be resolved through mediation or arbitration.
  • The laws of [State] govern this agreement.

5. Signatures

Client’s Signature

By signing below, the client acknowledges understanding and acceptance of the terms.

Client’s Full Name: __________________________ Date: __________________________

Caregiver’s Signature

By signing below, the caregiver confirms commitment to providing quality care.

Caregiver’s Full Name: __________________________ Date: __________________________