Family and provider agreement

Family and Provider Service Agreement

Use this agreement before services begin. The family and provider should review, complete, and sign it together. This form is a practical agreement template and is not legal advice.

1. Family Information Family or client name Parent, guardian, or adult client name Phone Email Service address or location

2. Provider Information Provider name or organization Provider contact person Phone Email License, certification, or credential if applicable

3. Services Service description Service start date Service end date or review date Schedule Care goals, needs, or expectations

4. Payment and Cancellation Provider rate or service fee Payment method Payment due date or timing Cancellation, rescheduling, late arrival, or no-show rules We understand the family and provider coordinate service payment directly unless a separate written agreement says otherwise.

5. Safety, Screening, and Responsibility The family understands it is responsible for deciding whether the provider is the right fit before services begin. The provider agrees the information shared about services, experience, licenses, credentials, and availability is accurate. We understand SentryLink provides background check information when used, and no background check, label, profile, or introduction guarantees safety, suitability, quality, or outcome. We understand Hope Care Connect and Hope Educational Services, LLC. do not guarantee service outcome, safety outcome, provider suitability, or payment between the family and provider.

6. Signatures

Records

The family and provider should each keep a signed copy for their records. A completed copy should also be provided to Hope Care Connect for HES records.

Family signature Date Provider signature Date Additional notes

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