Client Incident Report

A reportable incident is an event involving a individual, which has, or may have, an adverse effect on the life, health, or welfare of the individual.

Refer a client to us to become eligible for a referral bonus.  Click here to complete the form.

Clients Security Release

We understand some clients may not have family or friends nearby to assist them with confidential transactions and may request a CAREGiver or other Home Instead employee to help them with these activities. 

We advise all clients to consult with family members or a trusted advisor prior to allowing any individaul access to private information.  We have provided this authorization form for all parties to sign; the Office Staff will always sign off and return a fully executed copy to the client and we will retain a copy in our office.

Drug and Alcohol Policy 

Our Drug and Alcohol policy is put in place in order to guarantee safety within the workplace, or towards clients, and yourself against the misuse of drugs and alcohol. 

Employee Emergency Mgt Plan Form

Home Instead Senior Care has an emergency management plan in place to protect our employees and our clients.  Please read the PDF document and submit your information electronically by pressing the Submit button on the form.

Employee Injury Report

Recordable work-related injuries and illnesses are those that result in one or more of the following: medical treatment beyond first aid, one or more days away from work, restricted work or transfer to another job, diagnosis of a significant injury or illness, loss of consciousness, or death.  Employees must report an incident immediately and complete the Notice of Injury Form.

Employee Personal Info Change Form

Document your changes on this form and click submit.  The form will be automatically sent to the admin office who make the changes, generally within (3) business days.

Refer a CAREGiver to us to become eligible for a referral bonus.  Click here to complete the form.

Intake and Output Form

Intake and Output form for specialized service clients.

I've got a Brilliant Idea Form

Fill out this form to submit your ideas and suggestions that will help  our client's and CAREGiver have the best experience possible. 

Miscellaneous Expense Form

This form is for miscellaneous client expenses. Note:  Expenses for mileage, tolls and parking must be recorded on ClearCareGo app, not on this form.

Click on one of the reviews below to download the template document:

1. Key Player Annual Review
2. CAREGiver Annual Review
3. Introductory Period Review

PTO Policy & Accrual Chart 

Our paid time off request form is a document that is to be used by employees and staff to inform the human resource or the management about his/her intent to use their paid leave benefits. 

Time Off Request  Form

Timeframe for submitting requests:

Requests are to be made in writing on this form except in cases of emergency.  Submit requests no less than 30 days prior to your requested “time off” starting date.  You will need to submit multiple forms if more than one set of dates is being requested.

EMPLOYEE WITHHOLDING CERTIFICATE & TAXABLE TABLE

Please click on the links above to access a template W-4 and the Taxable table to guide you in determining your deductions.  Please download the W-4, and complete it.  You may send a scan or a picture of the completed form via email to boca.office@homeinstead.com.  Otherwise, please mail it to the office.