Client Intake Page

        Bonjour Home Care – Client Intake Form   

Bonjour – Client Intake Form

  All caregivers are Certified Home Health Aides (CHHAs), thoroughly screened, insured, and supervised by a Registered Nurse (RN). Clients are covered by general and professional liability insurance.

           
Client Information
  
    Primary Contact                                                     
  
    Secondary Contact                                                     
  
    Emergency Contact                                                               
  
    Payor Contact                                                               
LTCI / Long-Term Care Insurance Contact

Job Order / Plan of Care

Please select all applicable care types requested for this client. You may choose multiple options.

   
       1. HIPAA Notice of Privacy Practices      
    

      Bonjour Home Care is committed to protecting your personal health information (PHI) in accordance with the Health Insurance Portability and Accountability Act (HIPAA) and other applicable privacy regulations.     

    

How We May Use and Disclose Your Information:

    
          
  • Treatment: We may share your information with referred caregivers, nurses, physicians, or other providers involved in your care coordination.
    •       
  • Payment: We may use your information to process billing, coordinate with your insurance provider, or confirm coverage of services.
    •       
  • Health Care Operations: We may use your information to monitor service quality, conduct training, manage compliance audits, and maintain licensing requirements.
    •     
    

Other Situations Where We May Disclose Information Without Authorization:

    
          
  • When required by law (e.g., court order, law enforcement request, government audits)
    •       
  • To prevent or lessen a serious and imminent threat to your health or safety
    •       
  • For public health reporting or adult protective services in cases of suspected abuse or neglect
    •       
  • To comply with workers’ compensation laws
    •     
    

Your Rights Under HIPAA:

    
          
  • Right to Access: You may request to view or obtain a copy of your personal health information in our records.
    •       
  • Right to Amend: If you believe information we have is incorrect, you may request that we correct or supplement it.
    •       
  • Right to Restrict Use: You may ask us to limit the use or sharing of your information. We are not required to agree, but we will comply if reasonably possible.
    •       
  • Right to Confidential Communications: You can request that we contact you by specific means (e.g., by mail only or at an alternative phone number).
    •       
  • Right to a List of Disclosures: You may request an accounting of any disclosures of your PHI made without your consent.
    •       
  • Right to File a Complaint: If you believe your privacy rights have been violated, you may file a complaint with our office or with the U.S. Department of Health and Human Services. You will not be penalized for filing a complaint.
    •     
    

Our Responsibilities:

    
          
  • We are required by law to maintain the privacy of your PHI.
    •       
  • We will inform you if a breach occurs that may have compromised your PHI.
    •       
  • We must follow the terms of this Notice of Privacy Practices.
    •       
  • We may revise this notice at any time. Updated versions will be available upon request or posted on our website.
    •     
    

Contact Information:
      Bonjour Home Care
      210 Haven Avenue, Scotch Plains, NJ 07076
      Phone: (908) 447-4896
      Email: bonjourhomecare@gmail.com     

  
   
       2. Client Rights & Responsibilities      
    

      At Bonjour Home Care, we believe every client has the right to dignity, respect, safety, and transparency throughout the caregiving process. As part of our commitment to quality care, the following rights and responsibilities apply to all clients and their representatives.     

    

Your Rights:

    
          
  • The right to be treated with courtesy, compassion, and respect at all times.
    •       
  • The right to receive services without discrimination based on age, race, gender, sexual orientation, disability, religion, or national origin.
    •       
  • The right to be fully informed of all care services available, including any changes to your plan of care or caregiver assignment.
    •       
  • The right to participate in the development, review, and modification of your Plan of Care.
    •       
  • The right to request a change of caregiver at any time, for any reason.
    •       
  • The right to privacy and the confidentiality of your personal and medical information.
    •       
  • The right to voice grievances or file complaints without fear of retaliation.
    •       
  • The right to receive care in a safe and secure environment.
    •       
  • The right to refuse any services you do not wish to receive.
    •       
  • The right to terminate services with proper notice, as defined in our Service Agreement.
    •     
    

Your Responsibilities:

    
          
  • To provide accurate and complete information about your health, history, environment, and service needs.
    •       
  • To treat your caregiver(s) and agency staff with respect and courtesy.
    •       
  • To maintain a safe, clean, and accessible home environment for your caregiver to work in.
    •       
  • To notify Bonjour Home Care of any changes in your condition, contact information, schedule, or emergency instructions.
    •       
  • To communicate clearly if a service or caregiver does not meet your expectations, so we can resolve it promptly.
    •       
  • To follow the agreed-upon service plan and policies regarding hours, cancellations, and financial responsibilities.
    •       
  • To refrain from requesting caregivers to perform medical or prohibited tasks outside their scope of training.
    •       
  • To respect the terms of non-solicitation, confidentiality, and legal boundaries of care agreements.
    •     
    

      These rights and responsibilities are designed to ensure that the care relationship is built on mutual respect, clear communication, and shared commitment to safety and well-being.     

    

If you have questions or concerns:
    Please contact us anytime at:
    Bonjour Home Care
    210 Haven Avenue, Scotch Plains, NJ 07076
    Phone: (908) 447-4896
    Email: bonjourhomecare@gmail.com     

  
   
       3. Service Agreement Terms      
    

      This Service Agreement outlines the responsibilities, expectations, and protections for both the Client and Bonjour Home Care. By entering into this agreement, you acknowledge and accept the terms under which non-medical home care services are coordinated and delivered.     

    

Nature of Services:

    
          
  • Bonjour Home Care operates as a licensed referral registry. We connect clients with carefully screened and certified independent caregivers who provide non-medical services.
    •       
  • Caregivers referred to you through Bonjour are not employees of the agency but operate independently under the scope of non-medical support, supervised and guided by our Registered Nurse (RN).
    •     
    

Scheduling & Plan of Care:

    
          
  • All services are based on a Plan of Care developed in collaboration between the client (or representative) and our RN.
    •       
  • The Plan of Care outlines specific tasks, schedules, preferences, safety measures, and any relevant protocols.
    •       
  • Bonjour may revise the Plan of Care periodically based on the client’s needs or changes in condition.
    •     
    

Rates and Billing:

    
          
  • Service rates (hourly or live-in) are provided in your Care Estimate or Welcome Packet.
    •       
  • Major holidays are billed at time-and-a-half (1.5x standard rate). Overtime may apply if a caregiver exceeds 40 hours in a single week.
    •       
  • Invoices are sent weekly or bi-weekly and are payable upon receipt, unless other arrangements are made in writing.
    •       
  • Late payments may incur a late fee or collection referral after 30+ days.
    •     
    

Cancellation Policy:

    
          
  • We require at least 24 hours’ notice for any cancellation of scheduled care hours. Less notice may result in a cancellation fee equal to the scheduled shift’s value.
    •       
  • Frequent cancellations may result in reassignment or changes to scheduling policies.
    •     
    

Caregiver Matching & Supervision:

    
          
  • Bonjour will match you with a caregiver who fits your needs and preferences. If you are not satisfied, we will provide a replacement upon request.
    •       
  • All referred caregivers are Certified Home Health Aides (CHHAs) and are screened, insured, and supervised by a licensed RN.
    •       
  • Caregivers are not permitted to perform skilled nursing tasks, administer medication, or provide medical treatments.
    •     
    

Non-Solicitation Agreement:

    
          
  • Clients agree not to privately hire, solicit, or contract with any caregiver referred by Bonjour outside of this agreement for a period of 12 months after services end.
    •       
  • Violation of this clause may result in a $10,000 fee to Bonjour to cover referral, screening, and administrative costs.
    •     
    

Termination of Services:

    
          
  • Services may be terminated by the client at any time with reasonable written notice (minimum 24 hours).
    •       
  • Live-in services require four (4) weeks’ notice due to caregiver displacement and replacement scheduling.
    •       
  • Bonjour reserves the right to terminate services if safety, payment, or scope-of-care policies are violated.
    •     
    

Legal Disclosures:

    
          
  • This agreement does not establish employment, joint venture, or agency between the client and Bonjour Home Care.
    •       
  • All referred caregivers operate as independent professionals. Bonjour assumes no liability for care outside of the approved Plan of Care or care performed against policy.
    •     
    

Questions or Concerns:
    For any questions regarding this Service Agreement, please contact:
    Bonjour Home Care
    210 Haven Avenue, Scotch Plains, NJ 07076
    Phone: (908) 447-4896
    Email: bonjourhomecare@gmail.com     

  
       4. Scope of Care      
    

      Bonjour Home Care provides non-medical in-home care services through referred Certified Home Health Aides (CHHAs). These services are designed to support your daily living needs, maintain comfort and independence, and enhance quality of life — but they do not include clinical or medical treatments.     

    

Caregiver Services May Include:

    
          
  • Assistance with activities of daily living (ADLs): bathing, dressing, grooming, toileting, and feeding
    •       
  • Mobility support: transfers, walking, positioning, and fall prevention
    •       
  • Incontinence care and hygiene management
    •       
  • Meal preparation, hydration reminders, feeding assistance
    •       
  • Light housekeeping: laundry, linens, tidying client’s personal areas
    •       
  • Errands and incidental transportation (as permitted by care plan)
    •       
  • Companionship: social engagement, conversation, cognitive stimulation
    •       
  • Safety supervision and reminders for orientation or memory care
    •     
    

Caregiver Limitations:

    
          
  • Caregivers may not perform any clinical or invasive medical tasks
    •       
  • They are not permitted to administer medications, inject insulin, fill pill boxes, or manage controlled substances
    •       
  • Caregivers do not diagnose, treat, or manage medical conditions
    •       
  • They may not lift or move clients beyond safe handling procedures
    •       
  • Caregivers must follow the Plan of Care and decline any task outside its scope
    •     
    

Plan of Care Oversight:

    
          
  • Each client receives a personalized Plan of Care developed by our RN in collaboration with the client and/or representative
    •       
  • Plans are reviewed regularly and adjusted based on the client’s condition, preferences, and risk factors
    •       
  • Caregivers are oriented to the plan before beginning services
    •     
    

Emergency & Safety:

    
          
  • If an emergency occurs, caregivers will follow your emergency instructions or call 911 as appropriate
    •       
  • They will notify Bonjour and the listed emergency contact promptly
    •       
  • Caregivers are trained to recognize early warning signs and report them, but not to interpret or treat medical issues
    •     
    

      The goal of our care is to promote dignity, independence, and comfort — while protecting safety and ensuring services stay within the caregiver’s legal and professional scope.     

    

For more information or to update your care plan, contact:
    Bonjour Home Care
    210 Haven Avenue, Scotch Plains, NJ 07076
    Phone: (908) 447-4896
    Email: bonjourhomecare@gmail.com     

  
       5. Non-Solicitation Policy      
    

      To ensure the integrity of Bonjour Home Care’s referral registry, and to maintain fair working relationships with our network of caregivers, the following non-solicitation policy applies to all clients and their representatives.     

    

What This Policy Means:

    
          
  • Clients agree not to hire, solicit, or contract with any caregiver referred by Bonjour Home Care for private arrangements outside of Bonjour’s system.
    •       
  • This policy remains in effect during the time services are being provided and for twelve (12) months after services end.
    •       
  • Caregivers referred to you have agreed to this policy as part of their registry participation.
    •     
    

Why This Policy Exists:

    
          
  • Bonjour invests substantial resources in screening, credentialing, supervising, and matching caregivers for each client.
    •       
  • Private hiring outside the registry undermines safety protections, violates state regulations, and circumvents agency liability and support systems.
    •       
  • Maintaining professional boundaries ensures continuity, quality assurance, and accountability for all parties.
    •     
    

Consequences of Violating This Policy:

    
          
  • Violation of this agreement may result in a non-solicitation fee of $10,000 per caregiver, payable to Bonjour Home Care.
    •       
  • This amount is not a penalty, but a reasonable estimate of damages incurred through unauthorized recruitment or employment of referred personnel.
    •       
  • Bonjour reserves the right to pursue this fee through collections or legal action if necessary.
    •     
    

Requesting Direct Hire or Exemption:

    
          
  • If you wish to hire a referred caregiver directly, please contact our office to request a formal release and pay a negotiated placement fee (if applicable).
    •       
  • This process must be done in writing and confirmed by Bonjour before any private employment begins.
    •     
    

Reminder:
      This policy applies to all forms of solicitation, including offers of payment, housing, referral to other clients, or promises of future employment.     

    

We appreciate your partnership in upholding professional care standards.
    Bonjour Home Care
    210 Haven Avenue, Scotch Plains, NJ 07076
    Phone: (908) 447-4896
    Email: bonjourhomecare@gmail.com     

  
       6. Termination Policy      
    

      This termination policy outlines the procedures, notice periods, and mutual expectations for ending services between the client and Bonjour Home Care.     

    

Termination by the Client:

    
          
  • You may terminate services at any time with at least 24 hours’ notice for hourly or part-time care.
    •       
  • For live-in care arrangements, Bonjour requests a minimum of four (4) weeks’ written notice to ensure proper caregiver transition and housing coordination.
    •       
  • Early termination without notice may result in a final invoice for the scheduled service period, or applicable separation fees if required by labor protection laws (e.g., Domestic Worker Bill of Rights).
    •     
    

Termination by Bonjour Home Care:

    
          
  • Bonjour may suspend or terminate services under the following circumstances:
    •       
              
    • Repeated cancellations or no-shows without proper notice
      •         
    • Non-payment or consistent delays in payment beyond 30 days
      •         
    • Care needs have become clinical or exceed the non-medical caregiver’s legal scope
      •         
    • The home environment poses safety concerns for the caregiver (e.g., harassment, violence, unsanitary or hazardous conditions)
      •         
    • Violation of agency policies or ethical boundaries
      •       
          
  • In such cases, Bonjour will provide notice (verbal and/or written) and assist with care transition referrals if possible.
    •     
    

Final Billing:

    
          
  • All services rendered up to the date of termination will be invoiced and must be paid in full.
    •       
  • If services were prepaid, Bonjour will calculate and return any unused portion (minus any applicable cancellation charges or short-notice deductions).
    •     
    

Caregiver Transition:

    
          
  • If the termination is initiated by the caregiver, Bonjour will notify you immediately and coordinate a replacement as soon as available.
    •       
  • If a replacement is not possible within a safe time frame, we will offer alternate resources or refer you to other providers.
    •     
    

      We are committed to ensuring a respectful, transparent, and client-centered conclusion to services, whenever it becomes necessary to end or transfer care.     

    

Questions or concerns about this policy?
    Please contact us directly:
    Bonjour Home Care
    210 Haven Avenue, Scotch Plains, NJ 07076
    Phone: (908) 447-4896
    Email: bonjourhomecare@gmail.com     

  
       7. Out-of-Scope Services      
    

      Bonjour Home Care provides non-medical in-home care services through referred Certified Home Health Aides (CHHAs). While our caregivers offer essential daily living support, there are specific services they are not legally permitted or professionally trained to perform.     

    

Caregivers referred by Bonjour may not perform the following:

    
          
  • Administering injectable medications (including insulin)
    •       
  • Handling or administering controlled substances or narcotics
    •       
  • Managing intravenous (IV) lines, ports, or catheter irrigation
    •       
  • Performing wound care, bandage changes on surgical or open wounds
    •       
  • Filling or managing pill boxes / medication organizers
    •       
  • Providing medical advice, interpreting symptoms, or diagnosing any condition
    •       
  • Monitoring vital signs unless part of a self-monitoring plan by the client
    •       
  • Transporting clients in personal vehicles unless explicitly approved in the Plan of Care
    •       
  • Supervising or administering oxygen therapy, suction, or feeding tubes
    •       
  • Lifting or repositioning that exceeds safe mechanical or ergonomic limits
    •     
    

Why These Tasks Are Out of Scope:

    
          
  • Caregivers are licensed and trained as CHHAs (Certified Home Health Aides) — not nurses or medical providers
    •       
  • Performing medical tasks without licensure is not only unsafe, it is prohibited under New Jersey state law
    •       
  • Out-of-scope services may place clients, caregivers, and the agency at legal and physical risk
    •     
    

What to Do if Medical Services Are Needed:

    
          
  • Bonjour will assist you in coordinating with a licensed home health agency, nurse, or physician if clinical needs arise
    •       
  • You may request a care review to update your Plan of Care and ensure compliance with the caregiver’s role
    •       
  • Caregivers are instructed to report any client request that exceeds their certified scope to the agency immediately
    •     
    

      We appreciate your understanding and commitment to providing care within legal, safe, and ethical boundaries. This ensures the highest standard of safety for both the client and the caregiver.     

    

Questions about what your caregiver may or may not do?
    Contact us directly:
    Bonjour Home Care
    210 Haven Avenue, Scotch Plains, NJ 07076
    Phone: (908) 447-4896
    Email: bonjourhomecare@gmail.com     

  
       8. Client Bill of Rights Summary      
    

      Bonjour Home Care believes that every client has the right to receive high-quality, respectful, and safe care — delivered in a way that reflects their dignity, values, and preferences. This summary outlines your rights as a private-pay or long-term care insurance client.     

    

As a client of Bonjour Home Care, you have the right to:

    
          
  • Be treated with respect, compassion, and courtesy at all times.
    •       
  • Receive services free from discrimination, abuse, neglect, or exploitation.
    •       
  • Have your cultural, religious, and lifestyle values honored in the delivery of care.
    •       
  • Be fully informed of the scope of services offered and how those services are delivered.
    •       
  • Participate in the development and review of your Plan of Care.
    •       
  • Receive services that promote your dignity, independence, safety, and comfort.
    •       
  • Request or decline specific services or caregivers without retaliation.
    •       
  • File a complaint or express dissatisfaction without fear of discharge, denial of service, or mistreatment.
    •       
  • Receive timely and reasonable notice of any changes to your service schedule, caregiver assignment, or policies.
    •       
  • Have your personal health, home environment, and financial information kept strictly confidential.
    •       
  • Access your intake documentation and records upon request.
    •       
  • Be informed of all fees, billing procedures, and payment responsibilities in advance of care.
    •     
    

Your Voice Matters:

    
          
  • If you believe your rights have been violated or your service has not met your expectations, you have the right to speak up and be heard.
    •       
  • We encourage open dialogue and welcome your feedback at any time. All concerns are handled confidentially and respectfully.
    •     
    

For questions, concerns, or feedback regarding your rights, please contact:
    Bonjour Home Care
    210 Haven Avenue, Scotch Plains, NJ 07076
    Phone: (908) 447-4896
    Email: bonjourhomecare@gmail.com     

  
       9. Cancellation & Rescheduling Policy      
    

      This policy ensures that time is respected for both clients and caregivers. It also allows Bonjour Home Care to maintain fair scheduling practices and respond efficiently to care needs.     

    

Standard Cancellation Policy:

    
          
  • Hourly or Shift-Based Care: Cancellations must be made with at least 24 hours’ notice to avoid charges.
    •       
  • Live-In Care: Cancellations or schedule changes must be made with at least 4 weeks’ notice.
    •       
  • If you cancel with less than 24 hours’ notice, you may be billed for up to the full cost of the scheduled shift.
    •       
  • This applies to all scheduled services unless cancellation is due to a verified emergency or hospitalization.
    •     
    

Rescheduling a Visit:

    
          
  • If you wish to reschedule a shift, please notify Bonjour Home Care as early as possible — preferably more than 24 hours in advance.
    •       
  • We will do our best to reassign the caregiver based on availability, but same-day rescheduling is not guaranteed.
    •     
    

Caregiver-Initiated Cancellations:

    
          
  • If your caregiver becomes unavailable due to illness, emergency, or personal conflict, we will notify you immediately and offer a replacement if available.
    •       
  • You will not be charged for shifts that are cancelled by Bonjour or a caregiver, unless you request that the shift still be covered by a substitute.
    •     
    

No-Show or Repeated Cancellations:

    
          
  • If a caregiver arrives for a confirmed shift and no one is present or the client refuses care without prior notice, that visit may be billed in full.
    •       
  • Repeated last-minute cancellations may lead to reassignment of your case or adjustments to your schedule availability.
    •     
    

      We ask that you respect your caregiver’s time and communicate promptly about any changes. This helps us deliver reliable care and maintain a respectful professional relationship.     

    

To cancel or reschedule a visit, please contact:
    Bonjour Home Care
    210 Haven Avenue, Scotch Plains, NJ 07076
    Phone: (908) 447-4896
    Email: bonjourhomecare@gmail.com     

  
       10. Weather & Emergency Closure Policy      
    

      Bonjour Home Care is committed to maintaining safe and dependable service during inclement weather and regional emergencies. However, our top priority is the physical safety of our caregivers and clients.     

    

Inclement Weather (e.g., snowstorms, hurricanes, flooding):

    
          
  • In the event of extreme weather conditions, we may modify, delay, or cancel scheduled shifts for the safety of all parties involved.
    •       
  • If local or state authorities declare a weather emergency, road closure, or hazardous travel advisory, services may be suspended or rescheduled without penalty.
    •       
  • You will be notified as early as possible if your caregiver is unable to safely reach your home.
    •       
  • If services are suspended due to weather, we will offer to reschedule or provide alternate support as soon as conditions improve.
    •     
    

Client Preparedness:

    
          
  • Please ensure you have an emergency backup plan, especially if care is medically necessary or 24/7 supervision is typically required.
    •       
  • Clients are encouraged to keep extra medication, food, and emergency contacts easily accessible in case of unexpected schedule disruption.
    •       
  • If you anticipate being without power, phone service, or internet, please inform us in advance if possible.
    •     
    

Caregiver Emergency Cancellations:

    
          
  • If your assigned caregiver is personally affected by a storm, evacuation, or local emergency, we will notify you and attempt to reassign coverage if available.
    •       
  • Clients will not be billed for shifts canceled by the caregiver or Bonjour due to confirmed dangerous weather conditions.
    •     
    

State of Emergency or Natural Disaster:

    
          
  • In large-scale regional emergencies (e.g., statewide emergencies, hurricanes, wildfires), Bonjour may suspend services temporarily across multiple areas.
    •       
  • We will resume services once it is safe to do so and based on caregiver availability and client risk level.
    •     
    

      We appreciate your flexibility and understanding in these rare but important situations. Your safety and your caregiver’s safety are equally vital.     

    

For weather-related updates or emergencies, please contact:
    Bonjour Home Care
    210 Haven Avenue, Scotch Plains, NJ 07076
    Phone: (908) 447-4896
    Email: bonjourhomecare@gmail.com     

  
       11. Client Responsibilities for Supplies      
    

      In order to ensure safe, hygienic, and effective care delivery, all clients are responsible for providing the necessary personal supplies and protective equipment required to perform daily caregiving tasks.     

    

Essential Supplies the Client Must Provide:

    
          
  • Disposable gloves (latex-free preferred)
    •       
  • Personal hygiene products (soap, shampoo, lotion, deodorant, etc.)
    •       
  • Adult briefs, pads, or incontinence supplies (if applicable)
    •       
  • Toileting aids (wipes, bedpans, commodes, urinals, etc.)
    •       
  • Skin care creams, barrier ointments, or powders (as approved by physician)
    •       
  • Paper towels, tissues, and garbage bags
    •       
  • Face masks or hand sanitizer (if risk of illness or exposure)
    •     
    

Additional Supplies for Housekeeping Support:

    
          
  • Laundry detergent and fabric softener
    •       
  • Cleaning sprays, disinfectant wipes, or vinegar-based solutions
    •       
  • Toilet brush, sponges, gloves, mop/bucket, and trash liners
    •       
  • Microwave-safe or stovetop-safe cookware if meals are prepared on site
    •     
    

What Bonjour Provides:

    
          
  • Bonjour does not supply day-to-day personal products or household items
    •       
  • Caregivers are not expected to purchase supplies out of pocket
    •       
  • Bonjour may provide assistance in coordinating delivery or identifying suppliers for your needs (if necessary)
    •     
    

What Happens if Supplies Are Missing:

    
          
  • If essential items (like gloves, briefs, or hygiene supplies) are not available, the caregiver may not be able to safely perform personal care tasks
    •       
  • If repeated supply shortages occur, Bonjour may require a service hold until materials are available
    •       
  • To prevent any service interruption, please monitor and restock items as needed
    •     
    

      Our goal is to ensure your safety, dignity, and comfort. Thank you for helping us deliver high-quality care by maintaining a well-prepared environment.     

    

If you need help identifying required supplies, contact:
    Bonjour Home Care
    210 Haven Avenue, Scotch Plains, NJ 07076
    Phone: (908) 447-4896
    Email: bonjourhomecare@gmail.com     

  
       12. Pet & Environmental Safety Disclosure      
    

      Bonjour Home Care is committed to creating a safe and respectful work environment for caregivers, and a clean and calm environment for clients. This policy clarifies expectations around pets, smoking, and home conditions that could affect the safety or well-being of both the caregiver and the client.     

    

Pets in the Home:

    
          
  • We welcome homes with well-behaved pets. However, aggressive or unpredictable animals must be secured during all caregiver visits.
    •       
  • Caregivers are not responsible for pet care unless specifically noted in the Plan of Care (e.g., walking a dog or feeding a cat).
    •       
  • Bonjour reserves the right to suspend service if a pet is endangering a caregiver’s physical or emotional safety.
    •       
  • If your pet is protective, loud, or territorial, please inform us in advance so that we may plan accordingly.
    •     
    

Smoking & Air Quality:

    
          
  • We kindly request that clients and family members refrain from smoking indoors during or prior to scheduled caregiver visits.
    •       
  • Excessive smoke exposure may trigger allergic or asthmatic responses and could result in reassignment of a caregiver or suspension of services.
    •       
  • Bonjour reserves the right to decline service if smoking conditions are deemed unsafe or medically inappropriate for the assigned caregiver.
    •     
    

Cleanliness and Hazardous Environments:

    
          
  • The home must be maintained in a reasonably clean and sanitary condition to allow safe caregiving tasks.
    •       
  • Bonjour may place services on hold if the home environment poses risks such as hoarding, infestation (e.g., rodents, insects), mold, exposed wiring, or physical hazards.
    •       
  • We will work with the client or family to develop a solution if these conditions arise.
    •     
    

Weapons and Dangerous Items:

    
          
  • Any firearms or weapons in the home must be disclosed and safely secured at all times.
    •       
  • Caregivers have the right to leave the premises and report unsafe conditions without penalty.
    •     
    

      A safe and calm work environment protects both the caregiver and the client. We appreciate your commitment to providing a respectful and healthy space for everyone involved.     

    

Please contact us if you need help preparing your home for service:
    Bonjour Home Care
    210 Haven Avenue, Scotch Plains, NJ 07076
    Phone: (908) 447-4896
    Email: bonjourhomecare@gmail.com     

  
       13. Digital Communication Consent      
    

      Bonjour Home Care uses email, phone, and text messaging to communicate with clients and their authorized representatives regarding services, scheduling, and important updates. This section grants your consent for us to contact you electronically in a secure and respectful manner.     

    

Why We Use Electronic Communication:

    
          
  • To confirm or adjust your caregiver schedule
    •       
  • To send digital copies of forms, care plans, or intake paperwork
    •       
  • To provide real-time updates in the event of emergencies or caregiver changes
    •       
  • To respond to your requests for support or follow-up
    •     
    

Your Consent:

    
          
  • By signing this intake form, you authorize Bonjour Home Care to contact you via:         
                
    • Email (including sending PDFs and updates)
      •           
    • Text message (SMS) from a secure number
      •           
    • Phone call (including voicemail messages)
      •         
          
    •       
  • You may opt out of any of these communication methods at any time by contacting our office.
    •     
    

Your Privacy:

    
          
  • We will never share or sell your contact information.
    •       
  • We will never include sensitive medical or billing information in unsecured messages.
    •       
  • We follow all applicable privacy and communication regulations, including HIPAA for health-related correspondence.
    •     
    

      This consent allows us to stay connected and provide efficient, responsive care service. If you prefer to receive all communications by postal mail or landline only, please let us know during intake.     

    

Questions or changes to your contact preferences?
    Bonjour Home Care
    210 Haven Avenue, Scotch Plains, NJ 07076
    Phone: (908) 447-4896
    Email: bonjourhomecare@gmail.com     

  
       14. Infectious Disease & Illness Policy      
    

      To ensure a safe environment for both clients and caregivers, Bonjour Home Care maintains a common-sense policy regarding contagious illness, infection prevention, and home hygiene. This applies to all household members, not just the primary client.     

    

If the Client or Household Members are Sick:

    
          
  • If the client, caregiver, or anyone in the home has a confirmed or suspected contagious illness (e.g., flu, respiratory infection, COVID-19, RSV, norovirus), please inform us as soon as possible.
    •       
  • Services may be temporarily rescheduled or modified to ensure safety and reduce transmission risk.
    •       
  • Bonjour may recommend short-term protective protocols, including mask usage or remote caregiver support, if appropriate.
    •     
    

If the Caregiver Becomes Sick:

    
          
  • Caregivers are required to report symptoms of illness before arriving at your home.
    •       
  • Bonjour will notify you and attempt to reschedule or assign a temporary replacement if the caregiver cannot safely work.
    •     
    

Infection Prevention in the Home:

    
          
  • Caregivers are expected to wash hands frequently and follow standard hygiene practices while in your home.
    •       
  • We encourage clients to keep disinfectants, gloves, paper towels, and tissues readily available during all visits.
    •       
  • Homes should be ventilated and clean to allow safe care, especially when recovering from illness.
    •     
    

      Bonjour respects the privacy and medical autonomy of every household. We encourage open communication, shared respect, and mutual responsibility to help reduce exposure to infectious disease and protect all involved.     

    

Contact our office with any questions or to report illness:
    Bonjour Home Care
    210 Haven Avenue, Scotch Plains, NJ 07076
    Phone: (908) 447-4896
    Email: bonjourhomecare@gmail.com     

  
       15. Complaints & Conflict Resolution Policy      
    

      Bonjour Home Care is committed to maintaining a respectful, responsive, and high-integrity relationship with every client and caregiver. We believe that open communication and proactive problem-solving are key to successful care.     

    

If You Have a Concern or Complaint:

    
          
  • You are encouraged to share any concerns as soon as they arise — including dissatisfaction with services, caregiver behavior, scheduling issues, billing, or communication.
    •       
  • You may submit complaints verbally, in writing, or via email to our office. All concerns are treated confidentially.
    •       
  • You will not be penalized, discharged, or treated differently for submitting a complaint.
    •     
    

Our Response Process:

    
          
  • We will acknowledge your concern promptly and assign a supervisor or manager to follow up within 24–72 hours.
    •       
  • We may request additional details to fully understand the situation and ensure a fair resolution.
    •       
  • If a caregiver change is needed, we will coordinate a transition as quickly as possible.
    •       
  • We document all complaints and use them to improve quality and training over time.
    •     
    

What We Ask From You:

    
          
  • Please bring up your concerns calmly and respectfully, so we can resolve them together.
    •       
  • If a conflict involves a caregiver, we ask that you do not confront them directly in anger — contact our office to handle it professionally and protect everyone involved.
    •     
    

Escalation or Outside Support:

    
          
  • If your concern is not resolved to your satisfaction, you may request a case review by our RN Supervisor or a senior manager.
    •       
  • You may also request outside mediation or assistance if necessary. We will cooperate in good faith to reach a fair outcome.
    •     
    

      Our goal is not just to provide care, but to build long-term trust. We view your feedback as a vital part of our service.     

    

To submit a complaint or request support, contact:
    Bonjour Home Care
    210 Haven Avenue, Scotch Plains, NJ 07076
    Phone: (908) 447-4896
    Email: bonjourhomecare@gmail.com     

  
       16. Emergency Preparedness Statement      
    

      Bonjour Home Care is committed to providing consistent and dependable care, even during emergencies. However, due to the unpredictable nature of events such as power outages, storms, regional disasters, or public health emergencies, clients and families are encouraged to have a basic emergency preparedness plan in place.     

    

What Bonjour Will Do:

    
          
  • We will make every effort to maintain service during emergencies, provided it is safe for the caregiver to travel and conditions allow care to continue.
    •       
  • If services must be suspended, we will notify you as soon as possible and provide updates regarding rescheduling or reassignment.
    •       
  • We maintain internal contact trees and protocols to track staff and client status during area-wide events.
    •     
    

What We Recommend Clients Have on Hand:

    
          
  • Emergency contact numbers printed and visible in the home
    •       
  • Backup medical supplies, food, water, and personal care items for at least 3 days
    •       
  • A backup plan for supervision or medical support if live-in or hourly caregivers are temporarily unavailable
    •       
  • Flashlights, charged phones, and battery-operated medical equipment if needed
    •     
    

We Encourage Clients and Families To:

    
          
  • Inform Bonjour immediately of any emergency situation in the home or community
    •       
  • Let us know about known storm warnings, evacuation zones, or neighborhood threats that may affect safety or access to the home
    •       
  • Collaborate with us in advance if the client requires uninterrupted supervision or high-dependency care during emergency events
    •     
    

      While we will do everything we can to continue care through unexpected events, preparedness is a shared effort. Clear communication and planning help ensure continuity, safety, and peace of mind for everyone involved.     

    

If you have questions or would like help creating an emergency care plan:
    Bonjour Home Care
    210 Haven Avenue, Scotch Plains, NJ 07076
    Phone: (908) 447-4896
    Email: bonjourhomecare@gmail.com     

  
       17. Financial, Legal, and Driving Limitations      
    

      To maintain professional boundaries and ensure the legal protection of both caregivers and clients, Bonjour Home Care enforces the following limitations on caregiver roles regarding money management, legal responsibility, and transportation.     

    

Financial Boundaries:

    
          
  • Caregivers may not accept cash, gifts of value, checks, or gratuities from clients, unless pre-approved by Bonjour in writing.
    •       
  • Caregivers may not handle client bank cards, checks, account information, or financial documents under any circumstance.
    •       
  • If shopping or errands are part of the care plan, clients must provide written instructions and pre-authorized petty cash in a secure, trackable format (e.g., cash in envelope or prepaid card).
    •       
  • Caregivers must document all purchases with receipts and return all change unless otherwise directed by the care coordinator.
    •     
    

Legal Boundaries:

    
          
  • Caregivers may not witness, notarize, or assist with signing legal documents such as wills, power of attorney forms, medical directives, leases, or contracts.
    •       
  • Caregivers may not serve as a legal or healthcare proxy, beneficiary, or emergency contact unless authorized and documented formally by Bonjour and the client’s legal representative.
    •       
  • Caregivers may not offer legal advice or interpret legal or insurance paperwork for the client.
    •     
    

Transportation Boundaries:

    
          
  • Caregivers may only provide transportation if:         
                
    • It is documented in the Plan of Care, and
      •           
    • The caregiver has submitted a valid driver’s license, insurance, and liability coverage to Bonjour
      •         
          
    •       
  • Caregivers may not transport clients in their personal vehicle unless approved by Bonjour and the client assumes liability.
    •       
  • Clients must pay a mileage reimbursement fee (if applicable) and release Bonjour from transportation liability when using a caregiver’s vehicle.
    •     
    

Client Responsibility:

    
          
  • Clients and family members agree not to pressure caregivers into performing financial, legal, or transportation tasks outside of the approved care plan.
    •       
  • Bonjour will intervene immediately if a boundary is crossed and may reassign or suspend care if necessary.
    •     
    

      These policies are designed to keep everyone safe, clear, and protected — while allowing the caregiver to focus on compassionate, reliable care.     

    

Questions about caregiver limitations?
    Bonjour Home Care
    210 Haven Avenue, Scotch Plains, NJ 07076
    Phone: (908) 447-4896
    Email: bonjourhomecare@gmail.com     

  
       18. RN Oversight & Plan of Care Consent      
    

      As a licensed home care referral agency, Bonjour Home Care provides professional oversight and coordination of services under the supervision of a Registered Nurse (RN). This ensures your care is safe, customized, and aligned with both your goals and the caregiver’s certified scope of practice.     

    

Development of Plan of Care:

    
          
  • Each client receives a personalized Plan of Care created in collaboration with a licensed RN.
    •       
  • This plan includes your identified care needs, preferences, caregiver duties, schedule, and any specific protocols to follow (e.g., mobility concerns, transfer instructions, cognitive support).
    •       
  • You or your authorized representative will have the opportunity to review and approve this Plan of Care before services begin.
    •     
    

Ongoing RN Oversight Includes:

    
          
  • Periodic check-ins with the client or family to assess satisfaction and update goals as needed
    •       
  • Review of caregiver documentation and task follow-through
    •       
  • Support with adapting care if medical or behavioral conditions change
    •       
  • Assistance in identifying when a client may require additional clinical or nursing services
    •     
    

Consent to RN Contact:

    
          
  • By signing this intake, you agree to allow Bonjour’s supervising nurse to communicate with you or your representative to review care plans and follow up as needed.
    •       
  • All RN communications are treated as confidential and used only to ensure high-quality support and regulatory compliance.
    •     
    

Updating or Changing the Plan of Care:

    
          
  • You may request a care plan review at any time if your needs change or concerns arise.
    •       
  • Bonjour will notify you if any updates are needed based on caregiver feedback or RN assessment.
    •       
  • All updated plans are documented and shared for your signature or verbal confirmation.
    •     
    

      RN oversight helps keep care proactive, safe, and tailored to your evolving situation — while reinforcing the professional foundation of every caregiver match we coordinate.     

    

To discuss your plan of care or request an RN follow-up:
    Bonjour Home Care
    210 Haven Avenue, Scotch Plains, NJ 07076
    Phone: (908) 447-4896
    Email: bonjourhomecare@gmail.com     

  
       19. Emergency & Infrastructure Failure Contingency      
    

      While Bonjour Home Care makes every effort to remain operational during major disruptions, certain events may prevent our team from responding or communicating as we normally would. This section outlines what clients and caregivers should understand in the event of a citywide, statewide, or national emergency.     

    

Examples of Disruptive Events May Include:

    
          
  • Citywide power outage or grid failure
    •       
  • Road closures, fuel shortages, or weather lockdowns
    •       
  • Telecommunication or internet outages
    •       
  • Declared state or federal emergency (e.g., martial law, biological threat, large-scale unrest)
    •     
    

Important Limitations During a State of Emergency:

    
          
  • Bonjour Home Care may not be able to send staff, respond to phone/email, or provide on-site coordination if roads are closed, communication systems are down, or staff safety is at risk.
    •       
  • Caregivers already in the home (especially in live-in cases) will remain in place and continue care as they are safely able, unless conditions require them to evacuate or shelter in place themselves.
    •       
  • If a caregiver is not yet on site and an emergency begins, it is possible they may not be able to reach the home.
    •       
  • Bonjour is not a first-responder agency and does not replace 911 services. In any emergency involving life, health, fire, or safety, families must contact local emergency services.
    •     
    

Client & Household Emergency Readiness:

    
          
  • Clients receiving live-in or extended care are strongly encouraged to maintain a basic emergency supply in the home, including:         
                
    • Flashlights, candles, or battery-powered lanterns
      •           
    • Potable drinking water (3–7 day supply)
      •           
    • Non-perishable food
      •           
    • Manual can opener
      •           
    • Basic first aid kit
      •           
    • Spare medications (if possible)
      •           
    • Emergency contact numbers printed and posted visibly
      •         
          
    •       
  • Battery packs or solar chargers for communication devices are highly recommended.
    •     
    

If Caregivers Must Leave or Cannot Arrive:

    
          
  • If a caregiver is already in the home, they will shelter in place with the client to the extent that it is safe, ethical, and physically possible.
    •       
  • If a caregiver must leave due to danger, injury, or personal emergency, the client and family must rely on their own emergency plan and contact emergency services (911) if needed.
    •       
  • If a caregiver cannot reach the home due to lockdowns or road blocks, Bonjour will attempt to notify all parties when communications resume.
    •     
    

      Bonjour will always do our best to communicate, coordinate, and support clients and caregivers during any unexpected event — but certain disruptions may be beyond our control. We encourage all families to consider a basic personal safety plan in place for true emergencies.     

    

To request help developing an emergency plan or check readiness:
    Bonjour Home Care
    210 Haven Avenue, Scotch Plains, NJ 07076
    Phone: (908) 447-4896
    Email: bonjourhomecare@gmail.com     

  
       20. Caregiver Respect & Behavior Policy      
    

      Bonjour Home Care is committed to fostering a safe, respectful, and professional environment for both our clients and the caregivers we refer. The quality of care depends not only on the caregiver’s ability to serve, but also on their ability to do so in a space where they are treated with dignity.     

    

Respectful Conduct Toward Caregivers:

    
          
  • Clients and household members are expected to speak to caregivers respectfully at all times, using appropriate language and tone.
    •       
  • Physical intimidation, verbal threats, harassment, or demeaning behavior of any kind will not be tolerated and may result in immediate service suspension.
    •       
  • Caregivers have the right to report any concerns directly to Bonjour without fear of retaliation.
    •     
    

Boundaries & Reasonable Expectations:

    
          
  • Clients may not assign tasks to caregivers that are outside the Plan of Care or the caregiver’s legal role (e.g., medical care, financial management, cleaning unrelated areas of the home).
    •       
  • Clients may not ask caregivers to work outside of scheduled hours or to remain overnight without pre-approval from Bonjour.
    •       
  • Caregivers are not permitted to engage in personal relationships, private employment, or financial transactions with clients or their families.
    •     
    

Safe Working Conditions:

    
          
  • Caregivers must be able to perform their duties without risk to their health or well-being.
    •       
  • Clients are responsible for maintaining a safe and respectful home environment, free of aggression, illegal activity, or hazardous conditions.
    •       
  • If at any point a caregiver feels unsafe, they are instructed to contact Bonjour immediately and may leave the home until safety is restored.
    •     
    

Confidentiality & Professionalism:

    
          
  • Caregivers will maintain confidentiality and act with professionalism at all times.
    •       
  • Clients are also expected to respect the caregiver’s privacy and refrain from intrusive questions, personal boundaries violations, or unnecessary surveillance (e.g., hidden cameras).
    •     
    

      Bonjour believes care should be built on trust, mutual respect, and shared purpose. By working together in good faith, we create the environment where caregivers thrive — and clients receive the best care possible.     

    

To report any issue related to caregiver conduct or to address a concern:
    Bonjour Home Care
    210 Haven Avenue, Scotch Plains, NJ 07076
    Phone: (908) 447-4896
    Email: bonjourhomecare@gmail.com     

  
       21. Client Autonomy & Risk Assumption      
    

      Bonjour Home Care respects every client’s right to make decisions about their body, home, routines, and care experience. This includes the right to accept or decline services, instructions, or interventions offered by their caregiver.     

    

Your Right to Autonomy:

    
          
  • You have the right to refuse assistance with tasks such as bathing, eating, dressing, or mobility — even if these tasks are part of the approved Plan of Care.
    •       
  • You have the right to maintain your own daily schedule, diet, and lifestyle preferences to the extent they do not endanger your caregiver or violate policy.
    •       
  • You are not obligated to comply with suggestions from a caregiver or RN as long as your choice does not directly place others at risk.
    •     
    

Understanding the Consequences of Refusal:

    
          
  • If you decline services that are part of your approved Plan of Care, Bonjour and your caregiver will document the refusal and respect your wishes.
    •       
  • Repeated refusal of services such as hygiene assistance, hydration, or repositioning may increase risk of falls, skin breakdown, malnutrition, or injury.
    •       
  • If you consistently decline assistance and your condition worsens, Bonjour may request a care plan review or family intervention.
    •       
  • You (or your legal representative) assume responsibility for any risks or outcomes that may result from choosing to decline essential care.
    •     
    

Caregiver Limitations:

    
          
  • Caregivers may not force or coerce you to receive any service you refuse.
    •       
  • If a caregiver feels ethically uncomfortable or unsafe due to repeated refusal of care, Bonjour may reassign the case or pause services pending review.
    •     
    

      Your autonomy matters. We will always aim to find a solution that honors your independence while keeping care safe and respectful for everyone involved.     

    

To request a care plan review or discuss service concerns:
    Bonjour Home Care
    210 Haven Avenue, Scotch Plains, NJ 07076
    Phone: (908) 447-4896
    Email: bonjourhomecare@gmail.com     

  
       22. Timekeeping & Client Verification Policy      
    

      Bonjour Home Care uses a secure and compliant system to document caregiver attendance, time worked, and services rendered. Accurate timekeeping protects both clients and caregivers, ensures proper billing, and supports high-quality service monitoring.     

    

How Time is Tracked:

    
          
  • Caregivers record their time and tasks using a digital platform called ALLY — a secure, timekeeping and care coordination tool.
    •       
  • Time may be logged by mobile device, call-in system, or other approved method at the beginning and end of each visit.
    •       
  • Caregivers may also use Ally to record tasks completed and basic service notes, depending on the level of care provided.
    •     
    

Client Role in Verification:

    
          
  • You may be asked to verify visit times or sign off on caregiver hours using a mobile app, phone prompt, or physical signature.
    •       
  • Verification helps ensure billing accuracy, prevent fraud, and confirm that your care is being delivered as expected.
    •       
  • If you notice any discrepancy in time records, please notify Bonjour immediately.
    •     
    

What’s Included in Billable Time:

    
          
  • Hourly billing includes time spent providing care, completing tasks listed in your Plan of Care, and any reasonable documentation or reporting time.
    •       
  • For live-in arrangements, time is structured according to an agreed daily rate and schedule (typically including rest periods and standby coverage).
    •       
  • If your caregiver arrives early or stays late, you will only be billed for actual time worked as recorded through Ally unless otherwise agreed in advance.
    •     
    

Questions About Hours or Logs:

    
          
  • We are happy to provide a summary of logged hours at your request.
    •       
  • You may also request a breakdown of service categories or billed shifts.
    •       
  • All time records are backed up and monitored for quality assurance.
    •     
    

      Timekeeping through Ally helps ensure trust, transparency, and accountability. It also ensures we stay compliant with legal standards and insurance reporting requirements.     

    

Need help verifying hours or using Ally?
    Bonjour Home Care
    210 Haven Avenue, Scotch Plains, NJ 07076
    Phone: (908) 447-4896
    Email: bonjourhomecare@gmail.com     

  
       23. Caregiver Substitution & Absence Management      
    

      Bonjour Home Care understands that consistency is essential to a positive caregiving relationship. However, there may be times when a caregiver is unavailable due to illness, emergency, vacation, or other personal reasons. This policy outlines how we manage caregiver absences and substitute coverage.     

    

When a Caregiver is Absent:

    
          
  • Caregivers are required to notify Bonjour Home Care immediately if they are unable to attend a scheduled shift for any reason.
    •       
  • We will inform you as soon as possible if your caregiver cannot attend their visit and confirm whether you would like a substitute.
    •       
  • If you decline a substitute caregiver, you will not be billed for the missed shift.
    •     
    

Substitute Caregiver Assignments:

    
          
  • If you request coverage during your caregiver’s absence, Bonjour will assign a suitable substitute based on your care plan and preferences.
    •       
  • We will provide the substitute’s name and availability in advance, whenever possible.
    •       
  • You may decline any substitute caregiver at your discretion, and we will continue searching for an alternative if time allows.
    •     
    

Continuity of Care:

    
          
  • We do our best to minimize disruptions by maintaining notes, caregiver profiles, and care preferences in our system for all clients.
    •       
  • Substitute caregivers receive a summary of your Plan of Care and special instructions prior to the visit.
    •       
  • In the event of frequent caregiver changes or long-term absences, we may offer a formal care team rotation or re-matching.
    •     
    

Advance Notice of Caregiver Time Off:

    
          
  • If a caregiver schedules time off in advance, we will notify you and arrange for coverage if requested.
    •       
  • You are welcome to provide input on availability preferences or substitute caregiver traits during intake or any time throughout care.
    •     
    

      Our priority is to ensure your care is consistent, respectful, and uninterrupted whenever possible. While unexpected absences can occur, our system is designed to respond with speed, compassion, and coordination.     

    

Need to request a change or notify us of a coverage preference?
    Bonjour Home Care
    210 Haven Avenue, Scotch Plains, NJ 07076
    Phone: (908) 447-4896
    Email: bonjourhomecare@gmail.com     

  
       24. Safe Exit & Refusal of Entry by Caregiver      
    

      Bonjour Home Care is committed to protecting the physical, emotional, and legal safety of every caregiver we refer. While we aim to serve every client with compassion and consistency, there may be situations where a caregiver must leave a visit or decline to enter a home due to safety concerns.     

    

When a Caregiver May Leave a Visit or Refuse Entry:

    
          
  • If the home environment becomes hostile, threatening, abusive, or otherwise unsafe
    •       
  • If weapons, drug use, or illegal activity are present or suspected
    •       
  • If the client or another person in the home is verbally aggressive, intoxicated, or physically intimidating
    •       
  • If environmental conditions pose a health risk (e.g., infestation, dangerous pets, no heat or running water)
    •       
  • If access to the home is denied, or if the caregiver is made to feel unwelcome or at risk
    •     
    

Immediate Actions Taken:

    
          
  • The caregiver will contact Bonjour immediately to report the concern
    •       
  • Bonjour will attempt to reach the client or emergency contact to resolve the issue or provide alternative support
    •       
  • If needed, local authorities may be contacted to ensure safety or perform a wellness check
    •     
    

After a Safety Incident:

    
          
  • Bonjour may temporarily suspend services while the situation is investigated
    •       
  • A supervisor will follow up with the client or family to determine next steps
    •       
  • Services may resume, be reassigned, or be permanently discontinued depending on the nature and severity of the incident
    •     
    

We Understand:

    
          
  • We understand that misunderstandings or emotional outbursts can happen during times of stress or illness. We approach each case with care and professionalism.
    •       
  • However, we have a zero-tolerance policy for abuse of any kind — verbal, emotional, or physical.
    •     
    

      Our caregivers are professionals who deserve to feel safe while performing deeply personal and compassionate work. We appreciate your support in honoring that boundary.     

    

To report a safety issue or request a supervisor conversation:
    Bonjour Home Care
    210 Haven Avenue, Scotch Plains, NJ 07076
    Phone: (908) 447-4896
    Email: bonjourhomecare@gmail.com     

  
       25. Client Consent to Contact Representative or POA      
    

      Bonjour Home Care respects each client’s autonomy and right to privacy. However, in certain circumstances where a client’s health, safety, or ability to make informed decisions is in question, we may need to reach out to a listed representative or Power of Attorney (POA).     

    

What This Consent Covers:

    
          
  • If a client appears disoriented, unwell, or refuses essential care in a way that could lead to harm
    •       
  • If the caregiver observes potential cognitive decline, emotional distress, or behavioral changes affecting safety
    •       
  • If a client is unreachable for a scheduled visit and there is no explanation
    •       
  • If a safety-related incident occurs that requires a third party to assist with decision-making or home conditions
    •     
    

Who We May Contact:

    
          
  • The person(s) listed as emergency contacts, primary or secondary representatives, or POA on this intake form
    •       
  • In rare cases, adult protective services or local authorities if no contacts respond and an immediate risk is observed
    •     
    

Confidentiality & Sensitivity:

    
          
  • Only the minimum necessary information will be disclosed to convey the situation and ask for assistance or permission to proceed
    •       
  • Your privacy and dignity will be respected at all times
    •       
  • We do not share your information for any non-emergency or non-service-related purpose
    •     
    

Your Consent:

    
          
  • By signing this intake, you authorize Bonjour Home Care to contact your listed representative or POA if a situation arises that significantly impacts your safety or care continuity
    •       
  • You may update your emergency contacts or revoke this consent at any time by contacting our office
    •     
    

      This policy helps us advocate for your well-being while respecting your independence and preferences.     

    

To update contact preferences or discuss this policy:
    Bonjour Home Care
    210 Haven Avenue, Scotch Plains, NJ 07076
    Phone: (908) 447-4896
    Email: bonjourhomecare@gmail.com     

  
             

Client Signature & Confirmation

        

    By signing below, I acknowledge that I have read and understood all of the above policies,     and that the information I provided is true to the best of my knowledge.     I authorize Bonjour Home Care to begin care coordination based on this intake submission.   

     
              

You may upload more than one file. Accepted formats: PDF, DOC, JPG, PNG.

  
  
    
                  
    
                  
  
  
            
  
                 
     
    

Submit Intake Form

    

Click below to complete your intake. You’ll receive a confirmation email.

       

BONJOUR Senior Elder Home Care  
Serving New Jersey — 24/7 Support  
210 Haven Avenue, Scotch Plains, NJ 07076
+1 (908) 447-4896
info@bonjourhomecare.com

Find us on Google as:  BONJOUR Senior Elder Home Care Live In Agency In NJ Dementia Alzheimers Around The Clock Care at Home 24 Hours

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Alzheimer’s & Dementia Home Care
Live-in | Hourly | 24-Hour | Round-The-Clock-Home-Care | Overnight Care
Union • Morris • Essex • Somerset • Middlesex • Mercer • Counties

As part of our extended care network, we collaborate with 24 Hour Home Care NJ to ensure families receive reliable, personalized home care—day or night.

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