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Client Service Agreement Page 

All new clients and those renewing the service agreement for the services must read and agree to the service agreement. Agreement must be duly signed and dated for service to be scheduled or provided.

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SERVICE AGREEMENT FORM

Form Name
Individual Date of Birth
Month
Day
Year

Date the individual first contacted the provider for service

Date the idividual was refered to the provider

(State in Individual/Responsible Party’s own words. Descriptions should be specific, e.g. help in and out of bed, bathing, getting dressed, etc.)

Frequency of Service

How often does the individual need the service?

How long does the individual need the service to be provided?

Services Needed

Choose the type of service(s) needed

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