2019-04-05_aallard_Kathleen Keefler Client Consent .pdf

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Client Consent  Agreement 
Revised Date: 01/2019  
 
 
Client(s)  Name:     Kathleen Keefler   
This agreement is entered into on  (date) . April 04 2019  between the aforementioned Client(s) Name(s)  (hereafter  
referred  to as “Client”)  and Home  Care  Assistance  (Montreal)  Inc. (HCA).  
Consent to Receive  Services  
HCA is hereby authorized to provide companionship services to the Client. Client understands that HCA is a  non-
medical  agency  that does  not provide  medical  treatments.  Client  waives  any issues  of medical  liability  on HCA’s  part for 
the provision  of these  non-medical  services.  A general  description  of services  to be performed  is outlined  as a part of the 
initial  assessment  and updated  as modifications  become  necessary.  
HCA Caregiver  Agreement  
Client  understands  that HCA  spends  a significant  amount  of time,  money  and resources  in the process  of recruiting,  
screening,  hiring  and training  its caregivers  and therefore,  each  HCA  caregiver  is a valuable  asset  to HCA.  Client  further  
understands  that each  caregiver  who provides  home  care services  for the Client  (as designated  on weekly  billing  
invoices)  is prohibited  from  accepting  private  employment  from  Client  directly  (or indirectly  through  another  organization  / 
agency)  while  said caregiver  is employed  by HCA  or for a period  of three  (3) years  following  caregiver’s  termination  of 
employment  with HCA.  Accordingly,  should  Client  desire  to employ  an HCA  caregiver  who has provided  home  care 
services for Client in violation of such restrictions, Client agrees to pay HCA a one-time placement fee of  TEN  
THOUSAND  DOLLARS  ($10,000.00),  which  amount  shall  be due within  t e n ( 1 0 )  calendar  days  of employment  
of such  caregiver.  
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Rates & Hourly  Minimums           Initials  
Until  notice  is given  by HCA  to the contrary,  the rates  for care are as follows:  
Service  Type  Rate  PAD  Period  Notes  
Hourly Care - 12 or more hours per week*  
$24 - $30 per hour   
Minimum commi tment of 48 total hours of  service.  $27.50  
+Tax   per hour  PAD  
Home Care Assistance offers a rate reduction for 
payment by pre -authorized bank debit.   
 
Cancellations  received  less than  forty -eight 
(48) hours  before  a scheduled  visit will result  
in that shift  being  charged.  All schedule changes 
should be coordinated with the HCA office to ensure 
accurate staffing and  billing.   
 
Note A: Client who sends caregiver home early will 
be charged the full shift.  Live-In Care – Individual  $335 $325 per day  
Live-In Care - Couple  $350 $340  per day   Holiday  Rate  
HCA recognizes eight (8) holidays per year consisting  
of New Year’s Day, Easter Sunday, Victoria Day,  St-
Jean Baptist, Canada Day, Labour Day, Thanksgiving 
Day and Christmas Day. On these days for the entire  
twenty -four (24) hour period, our holiday rate will apply.  
Our holiday rate is one point five (1.5) times the regular 
rate for all  services.  
 Parking  – When services are rendered at a hospital,  
client may incur a caregiver parking charge  Mileage (if Caregiver ’s vehicle  is used)  $0.70  $0.70  per KM  
 CTM Interventionist  $51 $50 per hour  
 Non-Scheduled Care Manager Visit  $60 - per visit  
    
             
Meal & Rest Periods   
 
Caregivers are entitled to a thirty (30) minute break for each five (5) hours worked.      
Live-In care is defined as a twenty -four (24) hour shift which requires that a caregiver get at least six (6) – eight (8) hours of 
sleep at night and four (4) hours of break time spread throughout the day for meals and personal time. All meals within reason 
are to be provided for the caregiver by the client. Client understands that if a caregiver has any special dietary  restrictions or 
preferences that are not reasonable for client to adhere to, client is not obligated to do so. In gen eral, however, caregiver and 
client share the same meals. A place to obtain a mostly uninterrupted sleep period is required. This is a room other than the  
client’s bedroom, but maybe a sleep sofa, cot or a bed. Unless otherwise agreed, or in the case of

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Client Consent  Agreement 
Revised Date: 01/2019  
 
 
an emergency, the caregiver will not leave client premises during a scheduled shift. Client understands that circumstances 
beyond company’s control (e.g. client or caregiver short term illness, change in client sleep patterns, etc.) may require 
additional hours to be provided at the hourly rate specified above  
Security of  Caregiver  
Caregivers  are instructed  not to put themselves  at risk of bodily  harm  or injury  in the provision  of companionship  services. 
Thus, Client understands and acknowledges that, if a  Caregiver is made to reasonably feel threatened  and/or  is in 
physical danger while performing companionship services, the Caregiver is entitled to leave Client’s p r e m i s e s  without 
exposing the Caregiver and/or HCA, its affiliates, successors, assigns, dire ctors, trustees, officers, shareholders, 
employees, agents and representatives, to any liability and the Client remains liable for the full payment of  fees.  
Driver Release; Limitation of  Liability  
In recognition of the relative risks and benefits of servic es provided by Company, Client agrees to the fullest extent of the law, 
to limit the liability of Company, its affiliates, successors, assigns, directors, trustees, officers, shareholders, employee s, agents 
and representatives, for any and all claims, loss es, costs, damages of any nature whatsoever or expense from any cause or 
causes, including attorneys’ fees and costs, and costs of expert witness fees and costs, so that the total aggregate liabilit y of 
Company to the Client shall not exceed the total fees  payable to Company for services rendered. It is intended that this limitation 
apply to any and all liability or cause of action however alleged or arising. Further, Client releases Company, its affiliate s, 
successors, assigns, directors, trustees, officer s, shareholders, employees, agents and representatives, from any claims for 
liability which the Client may acquire by reason of damage, loss, injury and/or suffering which arises from the operation and /or 
use of a vehicle by a Caregiver, whether that may b e owned by the Client or a vehicle provided by the Caregiver or Company. 
Client also agrees not to hold Company, its affiliates, successors, assigns, directors, trustees, officers, shareholders, 
employees, agents and representatives, liable for any intenti onal acts of Caregivers acting beyond the course and scope of 
their duties to provide companionship services.  
Fall Risk  
Client understands that even with the provision of twenty -four (24) hour, around -the-clock companionship services,  
Clients  may potentially  experience  a fall. Client  understands  that Clients  with dementia,  Alzheimer’s  or any condition  
that causes  mental  confusion  are especially  at high risk for experiencing  falls.  Client  further  understands  that HCA  will 
do its best to minimize  fall risks,  and agrees  to hold HCA,  its affiliates, successors, assigns, directors, trustees, officers, 
shareholders, employees, agents and representatives, blameless  in the event of a fall.  
Certification of  Authority  
If someone other than Client(s) (hereafter referred to as an "Authorized Agent") signs this agreement on behalf  of 
Client(s), said Authorized Agent hereby certifies that he/she has the authority to enter into this agreement on be half of 
said Client(s)  and bind Client(s)  to the terms  hereof.  Furthermore,  said Authorized  Agent  accepts  full responsibility  
solidari ly with Client(s) for the payment of all fees incurred for services rendered to Client(s) pursuant to this agreement.  
Client or  Authorized  Agent  has read  and fully understands  the content  of this agreement  and agrees  to the terms  contained  
herein.  
X 
X   
Client or Authorized  Agent  Date  
 
 
Capacity of Authorized Agent in Relation to  Client