Home Care Client Intake Form

Heart And Home Alliance- Client Intake Form

Please complete this form to help understand your care needs. We will contact you shortly to discuss services and create a personalized care plan.
Full Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Who is this care for?

MyselfA family memberA friend or loved one
Home Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
What type of support is needed?*

Personal care (bathing, dressing, grooming)Medication remindersMeal preparationLight housekeepingCompanionshipMobility assistanceRespiteOvernight careOther
Please describe any specific care requirements or conditions:
Please select the preferred days and times of care. If you are unsure, choose the closest option or add details in the notes below.
Which days is care needed for?

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
What time of day is care needed?

MorningAfternoonEveningOvernight
Additional Notes ( Please include any additional details about care needs, preferred timing, or anything else you would like us to know).
Service Agreement
Heart and Home Alliance provides non-medical home support services, including personal care, companionship, meal preparation, and light houskeeping.

These services are supportive in nature and do not replace medical care, nursing care, or professional healthcare supervision.

Clients are responsible for seeking medical attention when required
Payment Terms
Services are provided at agreed-upon rates based on the type and duration of care.

A deposit is required at the time of booking to secure your apppointment. This deposit will be applied toward th total cost of the service and is non-refundable.

The remaining balance is due immediately upon completion of each service. Payment is expected at the end of the visit prior to caregiver's departure.

Payment may be made via E-transfer, credit, debit, or cash.

Heart & home Alliance does not offer invoicing or delayed payment arrangments at this time. Services may be paused or discontinued if payment is not received.

Booking, Deposit & Cancellation policy

A $25 deposit is required at the time of booking to secure your appointment. This deposit wi be applied toward your total service cost.

Deposits are non-refundable and cannot be returned once paid.

Appointments cancelled with more than 24 hours notice may have their deposit transferred to a future booking.

No-shows or cancellations within 24 hours will result in loss of deposit.

Remaining balance is due immediately upon completion of the service.
Acknowledgment of Risks
I understand that home care services may involve certain inherent risks, inluding but not limited to slips, falls, physical strain, and unforseen health-related events.

I acknowlege these risks and agree to receive services with this understanding.
Liability Wavier
I acknowledge that while all reasonable care and precautions will be taken, Heart and Home Alliance is not liable for any injuries, accidents, or unforseen events that may occur during the provision of services, except in cases of proven negligence or where otherwise required by law.
Client Responsibilities
I agree to provide accurate and complete information regarding care needs and to maintain a safe environment for service delivery.

I will communicate any changes in health, condition, or circumstances that may affect the services provided.
Clients Rights
I understand that, as a client, i have a right to:
- Be treated with dignity, respect and compassion.
- Receive clear and accurate information about services.
- Participate in decisions regarding my care.
- Client may discontinue services at any time with reasonabe notice.
- Have my personal information kept confidential in accordance with applicable privacy laws.
Consent and Agreement*

I have read, understood, and agree to the terms outlined above, including, the booking, deposit, and cancellation policy.
Signature Required*
Thank you for reaching out to Heart And Home Alliance. We will review your information and contact you shortly to discuss your care needs and how we can best support you or your loved one.
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Heart And Home Alliance- Client Intake Form

Service Agreement

Payment Terms

Acknowledgment of Risks

Liability Wavier

Client Responsibilities

Clients Rights