Client Forms

The Client and Undersigned consent to the following and all ancillary services (see attached Questionnaires) agreed upon under this Agreement.

The Undersigned or Client agrees to communicate all schedule changes to the RTSS Provider by methods of both voice mail and email. 

The Provider will acknowledge receipt of the Client’s notice and coordinate change of schedules by both voice mail and email.

The undersigned or Client will acknowledge agreement of schedule change by both voice mail and email.

The Provider will acknowledge receipt of the Client’s notice and coordinate change of schedules by both voice mail and email.

The undersigned or Client will acknowledge agreement of schedule change by both voice mail and email.

Entry to the Client’s home will be handled by the method of:

The Undersigned/Client agrees to provide a safe, free from hazards working environment at the Client’s address for the Provider at all times. The Undersigned/Client acknowledges that the Client’s address is free from hazards that would cause physical injury or bodily harm to the Provider.  The Undersigned/Client understands that Provider may conduct periodic and regular inspection at the Client’s address so as to verify the safety and security and will notify the Client/Undersigned any concerning issues that need to be addressed and rectified.

In the event of natural caused disaster such as electric outage, heavy snow, severe strong wind, aftermath of earth quake, flooding, or inclement of severe weather conditions that could put the Client or the Provider safety in jeopardy, the service will be cancelled by either party via voice mail and email notice.

In the event of announcement of closing from the government or the county school in the vicinity of the Client’s or Provider’s addresses, due inclement weather, the service will be

automatically cancelled.  The Provider will send a courtesy confirmation notice by email to the Client.

The Provider also advices the Client/Undersigned to find an alternative source of care to prevent unexpected event that renders the Provider not able to provide her services.

Any scheduled service canceled with less than 24-hour notice will result in the four (4) hour charge for the day’s shift.  The Undersigned/Client may cancel services with two (2) day notice by a notice via email.

The Provider may terminate the services for any reason with at least two (2) days via email except when discharge is terminated by RTSS that is deemed necessary to protect the health and welfare of the Provider or in the event of non-payment of a prior bill.

In the event that the Provider uses her own vehicle for a chore on behalf of the Client or an outing with the Client during the shift hours, there will be a charge of current year federal standard mileage rate $.57 cents per mile added to the regular service fee.

The mileage is calculated from the Client’s address indicated in the Agreement to the Client’s designated destination(s) and then back to the Client’s address.  The mileage is measured by the diameter mileage indicator on the Provider’s car. 

The Provider may use the Client’s vehicle for errands and incidental transportation with permission from the Client or Undersigned during the shift for the services. The Client agrees to and will maintain effective automobile insurance coverage for her/his vehicle with at least the minimum state statutory amounts as required by the laws of the state of Client’s residence during the term of this Agreement.  The vehicle insurance shall include coverage for authorized third-party drivers of such automobile. The Provider will not be held responsible for the unintentional accidents or damages of the Client’s vehicle while performing her duties within the shift hours.  By signing the initial the Undersigned and the Client grant the permission for the Client to use the Client’s vehicle and will show the Provider the car’s insurance policy before the start of service.

Services will be provided at the following rates for a single person or a couple.

From the time of TRSS Provider’s arrival at the Client’s address till the time Provider completed her agreed upon hours of senior companionship is considered a “shift”. 

(Monday–Sunday, 10 am-8 pm)

$30/hr companionship services with 4 hour minimum for each shift for a single person.

$35/hr companionship services with 4 hour minimum for each shift for a couple.

Payment for the shift fulfilled by the Provider shall be compensated by the following methods within 7 days from the date of billing (see Payment Terms).

            Cash, Personal Check

Undersigned and/or Client agrees to pay the Provider fees for the services provided under this Agreement within seven (7) days from the date of billing.  Undersigned and/or Client shall be responsible for all fees and expenses.

Interest on delinquent balances will be charged at a rate of 1.5% per month. Client also agrees to pay a $25.00 late fee if payment is not received within seven (7) days from the date of billing. A $25.00 Service charge will apply to all dishonored checks.

Attorney’s fees, costs and interest incurred when the Provider has to collect delinquent amounts owed to the Provider under this Agreement will be added at the final billing.

All service invoices will be sent to the Client/Undersigned:

Undersigned/Client fully acknowledges and agrees that the Provider: (a) is a provider of non-medical companionship services; (b) is not licensed or insured to perform skill medical services; and (c) shall not be liable for any bodily injury or property damages due the Client’s physical and mental limitation and condition.

Undersigned/Client fully acknowledges and agrees that the Provider: (a) is a provider of non-medical companionship services; (b) is not licensed or insured to perform skill medical services; and (c) shall not be liable for any bodily injury or property damages due the Client’s physical and mental limitation and condition.

The Undersigned/Client understands that should services require any protective equipment or specialized cleaning products, such as gloves, masks, goggles, alcohol, wipes, etc., the Provider will notify the Undersigned/Client by text messaging or email and the Undersigned/Client will purchase those products.  The Undersigned/Client also acknowledges will reimburse the Provider for all incidental purchases for the sake of the Client.  Provider has no responsibility for purchasing those items.

If any provision of this Agreement is deemed to be invalid or unenforceable to any extent, the remainder of this Agreement shall not be affected thereby and shall be enforced to the greatest extent permitted by law.

Undersigned/Client acknowledges that he/she has read and fully understands this entire Agreement and that by signing below, agrees with and accepts all the terms and conditions contained herein.

All Recycled Teenager Seniors Services (RTSS) clients have the rights to:

• Access RTSS services regardless of disability, color, race, ancestry, religion, sex or national origin.
• Be free from mental, physical and sexual abuse, neglect, and property exploitation.
• Be treated with dignity and respect.
• By fully informed in advance of the costs of services and receive proper notices of changes or increases in the fees.
• Voice grievances and complaints without fear of discrimination or retaliation.
• Have a compatible relationship with the RTSS providing services.
• Identify service needs and participate in planning the service schedule.
• Know the email address and telephone number of RTSS who provides the services.
• Verbalize preferences regarding activities and day-to-day schedule.
• Exercise freedom of choice regarding the availability of services from other agencies, and private companies in the community.
• Know RTSS’s capabilities and limits in providing services.
• Have personal privacy, respect for their property, and confidentiality of all RTSS records.
• Review your service agreement with a RTSS representative.
• Obtain a signed copy of your service agreement.
• Refuse services or terminate RTSS services with proper notices as indicated in the RTSS service agreement.