Please click here to view the pdf file of the Generic Form.
If you are preparing your own document, the areas highligted in yelllow in the pdf file need to be individualized with your own information by copying and pasting the text provided below:
Care Provider Services for the Person Requiring Care (PRC)
Address at which the caregiving service is required
Name of the Person Requiring Care (PRC) has Alzheimer’s Disease (memory loss). This is a degenerative disease, i.e., it gets worse over time. There is no cure and no treatment that appear to stop its spread in the brain. I(name and relation to the PRC) take care of name of the PRC. However, further assistance is sought from the care provider. Care giver with education in care giving and experience of taking care of Alzheimer’s patient is highly desired.
For the initial trial period of 1-week or less, the care provider will try to understand all the tasks to be performed for name of the PRC by observing(name and relation to the PRC), or other care giver, perform those tasks. After that, if both parties mutually decide to continue, the care provider to take care of most of the needs of (name of the PRC)and the household management as outlined below.
Assistance required with the following daily living activities of name of the PRC (name of the person in the house who could also assist, if required):
- Feeding meals (Breakfast around 9:30 am, and dinner around 6:30 pm - lunch on some days, if necessary)
- Toileting (after breakfast or as needed during the day)
- Hygiene / bathing / dressing / grooming (everyday)
- Lead name of the PRC in going from one place to another – toilet, sofa, chair, bed, etc.
- Companionship - Keeping name of the PRC engaged for his/her enjoyment during the day
- Oher special requirements: For example, walking with name of the PRC. name of the PRC enjoys walks of up to 2 to 3 miles (3 to 5 km) at a time on most days. The care provider must be able to accompany name of the PRC for the entire walks (every day – in warm weather outside otherwise, inside the local YMCA).
Meals cooking:Breakfast. Other meals to be determined
Light housework and household management:Daily / weekly general cleaning, maintenance and neatness of the areas listed below to be provided by the care provider
- Kitchen and eating Area
- Master bedroom and Master bathroom including the toilet and the floor cleaning
- Living room
- Den and foyer area
- Laundry (3 to 4 times a week, or as needed)
Care provider’s personality:
- Agility: Sometimes, name of the PRC ;may exhibit sudden change in his/her behavior. The care provider must be agile / alert to anticipate such behavior to handle it appropriately.
- Flexibility: It is essential that the care provider be flexible to adapt her lifestyle to that of name of the PRC and her name of the relation to PRC. Also, show flexibility and be adapt to the changing medical conditions and behavior of name of the PRC.
- It is essential that the care provider has intangible quality / personality characterized by being pleasant, courteous, non-frustrated and supportive of name of the PRC and his/her family.
- The care provider must have patience, love, mercy and compassion in taking care of ;name of the PRC.
Care provider to arrange her own transportation to and from my place. if the care provider does not drive, transportation arrangement needs to be discussed.
Room and Board (if caregiver needs to spend the nights to take care of name of the PRC):
Room and board will be provided to the care provider. Our master bedroom is on the first floor. There are three bedrooms on the second floor. One bedroom on the second floor will be provided to the care provider to sleep and keep few personal belongings. The care provider will be provided with reasonable amenities such as, towel, sheets, access to bathroom and shower, place for daily prayers (if required).