Client Service Agreement — Non-Medical Home Care Services (Ontario)
9 Carriage Lane, Wasaga Beach, ON L9Z 0L8 · 416-402-4492 · rightsitehomecare@gmail.com
This Agreement is made on (date):
Between RightSite Home Care Inc. (“the Agency”) and the Client / Substitute Decision-Maker:
Name:
Address:
Phone:
1. Purpose & 2. Scope of Services
The Agency provides non-medical support services only, which may include personal care (bathing, dressing, grooming), companionship and supervision, meal preparation, light housekeeping, mobility and transfer assistance, and errands and daily living support.
The Agency does not provide medical, nursing, or clinical services.
Specific services are detailed in the Plan of Care, which forms part of this Agreement.
4. Service Schedule
Days of service:
Hours of service:
Start date:
Minimum hours per visit (if applicable):
5. Fees and Payment
Hourly rate: $per hour
Invoices due withindays
Billing frequency:
Payment method:
6. Cancellations
Cancellations requirehours’ notice.
Late cancellations or no-shows may be billed at the scheduled rate.
7.–14. Responsibilities, Privacy, Consent & Terms
The Client agrees to provide accurate information, maintain a safe and respectful home, inform the Agency of changes, and secure pets during service hours. The Agency complies with Ontario’s PHIPA (see separate PHIPA Consent). By signing, the Client consents to receiving non-medical home care, caregivers entering the home, and emergency services being contacted when necessary. Complaints may be directed to the Manager at ComplaintsRightsite@gmail.com. Either party may terminate with written notice (except for non-payment, safety concerns, or abuse/harassment of staff). This Agreement, with the Plan of Care and PHIPA Consent, is the entire agreement and is governed by the laws of Ontario.
Termination written notice required:days
15. Agreement Acceptance
By signing below, both parties confirm they understand and agree to the terms of this Agreement.
Client / Substitute Decision-Maker
Name:
Relationship (if applicable):
Signature:
Date:
For RightSite Home Care Inc. — Director
Signature:
Date:
RightSite Home Care Inc. · Client Service Agreement · www.rightsitehomecare.ca
RightSite Home Care Inc.
Plan of Care — Non-Medical Home Care (Ontario)
9 Carriage Lane, Wasaga Beach, ON L9Z 0L8 · 416-402-4492 · rightsitehomecare@gmail.com
Client name:
Date of birth:
Address:
Phone:
Emergency contact:
Relationship:
Emergency contact phone:
1. Care Goals
What the client wants to achieve — comfort, independence, safety, companionship, etc.
2. Services Required
3. Mobility & Safety
Mobility level:
Fall risk:
Safety concerns (stairs, pets, smoking, etc.):
4. Daily Routine & Preferences
Morning routine, meals, likes/dislikes, cultural or religious preferences.
5. Health & Support Information (Non-Medical)
Diagnosed conditions (optional):
Allergies (if any):
Cognitive status:
6. Schedule of Care
Days:
Time:
Start date:
7. Tasks NOT Permitted
No medication administration
No medical procedures
Additional restrictions:
9. Acknowledgement
I confirm that this Plan of Care reflects the client’s current needs and preferences.
Client / SDM name:
Relationship (if applicable):
Signature:
Date:
Agency representative:
Date:
RightSite Home Care Inc. · Plan of Care · www.rightsitehomecare.ca
RightSite Home Care Inc.
PHIPA Consent & Privacy Notice (Ontario)
9 Carriage Lane, Wasaga Beach, ON L9Z 0L8 · 416-402-4492 · rightsitehomecare@gmail.com
1. Purpose
This form explains how RightSite Home Care Inc. collects, uses, and protects your personal and health information in accordance with Ontario’s Personal Health Information Protection Act (PHIPA).
2. Information We Collect
Name, address, phone number, and date of birth
Emergency contacts
Care needs and preferences
Safety-related information needed to provide home care
We collect only what is necessary to provide safe and appropriate non-medical home care services.
3. How Information Is Used
Develop and update your Plan of Care
Schedule and provide home care services
Communicate with you or your authorized contacts
Ensure safety and quality of care
Meet legal and regulatory requirements
4. Sharing of Information
Shared only with caregivers providing your services, authorized family/substitute decision-makers, emergency services (in emergencies), or when required by law. We do not sell or use your information for marketing.
5.–6. Storage, Protection & Your Rights
We take reasonable steps to protect your information. You have the right to access your information, request corrections, withdraw consent (with reasonable notice), and make a privacy complaint.
7. Consent
I confirm that I have read and understood this Privacy Notice. I consent to the collection, use, and disclosure of my personal and health information as described above.
Client / SDM name:
Signature:
Date:
If Substitute Decision-Maker, relationship to client:
RightSite Home Care Inc. · PHIPA Consent & Privacy Notice · www.rightsitehomecare.ca
