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Professional Individual Service Plan template for Adult Family Homes. Includes editable Word (.docx) and printable PDF formats.
[YOUR ADULT FAMILY HOME NAME HERE]
TEMPLATE • Inspection-Ready AFH Standard
This agreement is entered into on this _____ day of ____________, 20___, between [ADULT FAMILY HOME NAME] (Provider) and [RESIDENT / POA NAME].
Base Rate & Payment Schedule: Resident agrees to pay Provider a monthly base fee of $______ payable in advance on the first (1st) day of each calendar month.
Provider Signature / Date
Resident / POA Signature / Date
Get immediate access to the complete, unblurred Microsoft Word (.docx) and PDF files.
Bathing, dressing, mobility, eating, toileting, and transfer assistance levels.
Primary physician, specialist contacts, preferred hospital, and emergency care preferences.
Daily care routines, night checks, dietary needs, and caregiver instructions.
Social activities, personal hobbies, communication preferences, and personal goals.
6-month evaluation timeline, family review sign-off, and RN delegation notes.
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