Report this item to Etsy

Home Care Client Intake Forms, In Home Assessment, Care Plan Template, Service Agreement, Caregiver Visit Notes, Editable Word

Price:$29.00

Includes Etsy Purchase Protection

You can only make an offer when buying a single item

Highlights

  • Digital download
  • Digital file type(s): 1 ZIP

20 editable client forms for non-medical home care agencies, from the first phone call to discharge (59 pages, Word + PDF).

FORMS
• Client inquiry form
• Client intake form
• In-home assessment: ADLs and IADLs on a 0-4 scale, cognition, mobility, fall-risk screen, nutrition
• Room-by-room home safety checklist
• Plan of care with weekly task grid
• Client service agreement (15 sections: rates, minimum shifts, cancellations, caregiver buyout, termination)
• Client rights & responsibilities
• 6 consents: services, photo/media, release of information, key/lockbox, transportation, errands & money
• Emergency information sheet
• Medication reminder log
• Caregiver daily visit note & timesheet
• Supervisory visit report
• Change in condition report
• Client satisfaction survey
• Discharge summary
• Notice of termination/transfer letter

IMPORTANT
These are editable templates for informational purposes. They are not legal advice and are not approved by any government agency. Licensing rules differ by state and change over time. Review everything against your state's current requirements, and with a qualified attorney or consultant, before you use it.

LICENSE
One agency license: use and edit the files for your own business. Please do not resell or share them.

DIGITAL DOWNLOAD
No physical item will be shipped. Files: Word (.docx), PDF and Excel (.xlsx). Works with Microsoft Word, Google Docs, Excel, Google Sheets, LibreOffice and Apple Pages.

Instant Download

Your files will be available to download once payment is confirmed.  Here's how.

Instant download items don’t accept returns, exchanges or cancellations. Please contact the seller about any problems with your order.

Etsy Purchase Protection
Shop confidently on Etsy knowing if something goes wrong with an order, we've got your back for all eligible purchases — see program terms

You may also like

Shoppers with similar taste loved these

Show more
Show more

Explore related searches

Home Care Agency Templates

Home Care Agreement

Non Medical Home Care

Listed on Oct 14, 2026
Homepage Paper & Party Supplies Paper Stationery Design & Templates Templates Contract & Agreement Templates