Residential Adult Care Order Form

Private Residence Adult Service Order Form

Contact Information

Care Schedule

Extended Service Dates

Care Information

For Travel requests: *Round Trip transportation is to be provided by client.

By completing this service order form and signing the credit card authorization, I authorize Family Care Options, Inc. to charge the credit card provided for all services rendered. I understand that a 4% service fee applies to telephone and online transactions.

Billing & Rates: Service rates are available on our website and upon request. All services are billed in hourly increments, with a 5-hour minimum for adult care and a $50 return transportation fee if the caregiver works past 9:00 PM. Upon confirming the care and schedule stated in this order form, a confirmation will be emailed confirming the services, and any additional services beyond the confirmed schedule will be charged accordingly.

Private Residential Adult Care: $55.00/hour (minimum 5 hours) for up to 1 adult.

Transportation Surcharge: $50.00 for return transportation after 9:00 PM.

Cancellation Policy:

Cancellations received less than 48 hours before the scheduled start time, the client will be responsible and billed for the entire schedule of services confirmed. All hourly rates and transportation fees will be charged to the credit card provided.

Cancellations received more than 48 hours in advance will receive a refund.

Staffing Adjustments: Family Care Options may replace the confirmed caregiver/staff without prior notice if necessary, including but not limited to health-related reasons. Adjustments will be made to ensure the client's needs are met according to the original service order.

Health Disclosure: By signing below, I confirm that I have disclosed all relevant health information regarding the child(ren) receiving care. I understand that failure to provide accurate health details may compromise care quality and release Family Care Options from any and/all liability related to undisclosed conditions.

Toys & Food: Caregivers are not permitted to bring outside toys or food.

Payment & Confirmation: Upon submission, services will be confirmed, and the credit card provided will be charged. All major credit cards are accepted.

For more details, rates, or company policies, please call our office at (212) 748-8377 or email [email protected] before submitting this form.