Weekly Time Sheet & Service Log

Weekly Time Sheet & Service Log

FAX TO: 1-888-502-3059

No Cover Page Needed.

MUST BE RECEIVED NO LATER THAN NOON EVERY MONDAY.

X

EMAIL TO:

Place an

in the column of each activity performed on that day

Companion Client Services

Personal Care Client Services

Client Name:

Additional Instructions:

Personal Care Services should only be performed if

indicated by the office that these services are part of

Caregiver

the Care Plan. If the client's "normal" status has

changed please make note of it!

Time

Hours

Miles

Date

Other Activities/Daily Notes

In

Time Out

Worked

Driven

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Other Notes

(Please elaborate if you checked "change in status")

Total

TERMS & CONDITIONS

The signatures below (of the caregiver and client, or the client's authorized agent) indicate agreement as to the number of hours worked for the week listed and indicate agreement as to the services performed as indicated. The client

or authorized agent understands that invoices will be generated from this information and mailed on a bi-weekly basis (unless otherwise specified on your Service Agreement). Invoices are due upon reciept. Caregiver understands

that failure to complete this time sheet and forward to, by hand, mail, email or fax, the corporate office of Senior Helpers by 5:00PM each Monday will result in a delayed payment.

I certify the time and activities indicated on this time sheet and daily log to be true and

Client Name or Authorized Agent Printed

accurate.

Client or Authorized Agent Signature

Date

Caregiver Signature

Date