Personal Care Agreement Sample Template

Updated at March 6th, 2026

Table of Contents

Personal Care & Financial Agreement for __________________ 1. Caregivers & Financial Participants 2. Daily Care & Task Responsibilities 3. Weekly / Rotating Schedule Time Off and Self-Care Plan 4. Financial Responsibilities Caregiver Compensation (if applicable) 5. Communication & Documentation 6. Emergency Plan 7. Agreement & Signatures

Personal Care & Financial Agreement for __________________

Purpose:
This agreement clarifies caregiving responsibilities and financial roles among family members or other caregivers for ____________________, who has dementia. Its goal is safe, consistent care and transparent management of resources. It is intended to be a template, and may not be comprehensive. Please feel free to add to it if you find that there are specific needs that need to be agreed upon, that are not listed here.

Important Note: This document is not legally binding. It is intended as a guidance tool to help caregivers coordinate duties and finances, reduce conflict, and ensure consistent care. It does not create legal obligations or rights.

Care Recipient: ________________________
Date of Birth: ________________________
Primary Address: ________________________
Primary Contact: ________________________

1. Caregivers & Financial Participants

Name	Relationship	Phone / Email	Role (Care / Financial / Both)	Notes / Strengths
________________________	________________________	________________________	________________________	________________________
________________________	________________________	________________________	________________________	________________________
________________________	________________________	________________________	________________________	________________________

2. Daily Care & Task Responsibilities

Caregivers fill in initials or names for each task by time of day.

Task	Morning	Afternoon	Evening	Notes / Special Instructions
Bathing / Hygiene	______	______	______	________________________
Dressing / Grooming	______	______	______	________________________
Toileting / Incontinence Care	______	______	______	________________________
Medication Management	______	______	______	________________________
Meals / Groceries	______	______	______	________________________
Mobility / Transfers	______	______	______	________________________
Exercise / Activity	______	______	______	________________________
Social Visits / Check-ins	______	______	______	________________________
Appointments / Transportation	______	______	______	________________________
Home Safety Checks	______	______	______	________________________
Technology Assistance (smart devices, monitoring)	______	______	______	________________________
Respite Coordination	______	______	______	________________________
Finances / Bills	______	______	______	________________________
Safety / Supervision	______	______	______	________________________

3. Weekly / Rotating Schedule

Day	Time	Primary Caregiver	Secondary / Backup	Notes
Monday	______ – ______	______	______	______
Tuesday	______ – ______	______	______	______
Wednesday	______ – ______	______	______	______
Thursday	______ – ______	______	______	______
Friday	______ – ______	______	______	______
Saturday	______ – ______	______	______	______
Sunday	______ – ______	______	______	______

Time Off and Self-Care Plan

Providing care can be demanding, and regular breaks help maintain the caregiver’s well-being and ability to provide safe, consistent care.

Planned Breaks
(Example: One weekend off per month)
__________________________________
__________________________________
__________________________________

Backup Plan When Caregiver Is Unavailable
☐ Paid substitute caregiver
☐ Another family member: __________________________________

Sick Time Policy

4. Financial Responsibilities

Item / Expense	Responsible Caregiver(s)	Payment Method	Amount / Notes	Frequency
Monthly room & board	______	______	$______	______
Medications & supplements	______	______	$______	______
Medical appointments / copays	______	______	$______	______
Home care aides / respite	______	______	$______	______
Transportation / gas / rideshares	______	______	$______	______
Supplies / adaptive equipment	______	______	$______	______
Groceries / meal services	______	______	$______	______
Emergency / unexpected expenses	______	______	$______	______
Other bills / financial management	______	______	$______	______

Notes / Agreements:

Payments, reimbursements, and bookkeeping responsibilities should be clearly documented.

Receipts should be kept for shared review.

Any changes to financial contributions or allocations should be agreed upon collectively.

Caregiver Compensation (if applicable)

Caregivers will be compensated for their time providing care.

Pay Rate

$________ per hour or

$________ per month

Payment Method
☐ Check
☐ Direct deposit
☐ Cash

Payment Schedule
☐ Weekly
☐ Bi-weekly
☐ Monthly

5. Communication & Documentation

Caregivers will maintain a shared log for daily care, incidents, medications, and financial expenditures.

Weekly check-ins for care and financial review.

Preferred communication tools: _________________________ (journal, app, email, shared spreadsheet)

6. Emergency Plan

Emergency Contacts:

Physician: ________________________ Phone: ________________________

Hospital: ________________________ Phone: ________________________

Family / Backup: ________________________ Phone: ________________________

Steps in an emergency: ____________________________________________

7. Agreement & Signatures

By signing, all caregivers and financial participants agree to follow the responsibilities outlined above to the best of their ability and commit to communicating effectively.

This document is not legally binding and serves as a guidance tool only.

Name	Signature	Date	Role (Care / Financial / Both)	Notes / Comments
________________________	___________	___ / ___ / ___	___________	____________________________________________
________________________	___________	___ / ___ / ___	___________	____________________________________________
________________________	___________	___ / ___ / ___	___________	____________________________________________
[Care Recipient (if able)]	___________	___ / ___ / ___	___________	____________________________________________
______________________ (witness, optional)	___________	___ / ___ / ___	___________	____________________________________________

Additional Notes / Preferences:

personal agreement care contract