SERVICE AGREEMENT & CONSENT FORM

NewBridge Support
(416) 720-5772
hello@newbridgesupport.ca

Client Name: ___________________________________ Date of Birth: ____________
Address: ____________________________________________________________
City/Province/Postal Code: _______________________________________________
Phone: _________________ Email: _______________________________________
Primary Contact (if different): ______________________ Relationship: ______________
Phone/Email: _________________________________________________________

EMERGENCY CONTACTS
Emergency Contact Name: ___________________________ Relationship: ___________
Phone: _________________ Alternate Emergency Contact: _______________________
Relationship: ______________ Phone: _______________

1. SERVICES PROVIDED
Services include:
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Other: ________________________________________________________________
Service Preferences: Preferred Days/Times: _______________________________________
Special Requirements/Accommodations: ____________
Language Preferences: _____________ Mobility/Accessibility Needs: ___________________
Please note: Medical care, administering medications, or personal hygiene support are not provided.

2. RATES & PAYMENTS
Service Type: ☐ Individual Sessions ☐ Monthly Subscription

• Individual Sessions:

Tier Selected: ☐ Essentials ($19/hr) ☐ Enriched ($25-35/hr) ☐ Premium ($35-45/hr)
Hourly Rate: $________ /hour. Total Hours Booked: ________ hours

• Monthly Subscription:

Package Selected: ☐ Starter (8 hrs/month) - $ /month ☐ Professional (12 hrs/month) - $ /month
☐ Business (20 hrs/month) - $/month
Total Amount To be Paid: $____________
Payment Due: ☐ After each session ☐ Weekly ☐ MonthlyAuto-Renewal: ☐ Yes ☐ No
Accepted Payment: ☐ E-transfer ☐ Cash ☐ Credit Card ☐ Other: _________
Billing Address (if different from service address):
Cancellation Policy: Please provide 24 hours’ notice to cancel
Please note: Emergency/rush requests (within 24 hours) are subject to a $5 per hour surcharge

3. CLIENT RESPONSIBILITY & CONSENT
I understand that:
- I am voluntarily choosing to use the services of NewBridge Support
- I may decline any service at any time
- All information I share is confidential and protected under PHIPA
- The provider is not a licensed medical or nursing professional
- Services may be discontinued with 7 days written notice from either party
- Unused subscription hours expire monthly unless otherwise specified
- I agree to provide a safe working environment for service providers
- Pets must be secured during service visits when applicable
- I give consent for NewBridge Support to contact my emergency contact or healthcare providers
if required for my safety or care coordination

Health & Safety Information
Health Conditions/Allergies to be aware of: ______________________________________
Current Medications: _____________________________________________________
Other Safety Considerations: ________________________________________________

4. PRIVACY & CONFIDENTIALITY
All personal and health-related information will be protected under Ontario’s PHIPA legislation.
Your information will never be shared without written or verbal consent, unless required by law
or in case of emergency.
Preferred Communication Method: ☐ Phone ☐ Email ☐ Text Message ☐ Other: _______

5. LIABILITY & INSURANCE
I understand that NewBridge Support carries appropriate liability insurance. I agree to hold harmless
NewBridge Support for any accidents or injuries not resulting from negligence. NewBridge Support is
not liable for pre-existing conditions or health emergencies unrelated to services provided.

6. ACKNOWLEDGMENT & SIGNATURE
I confirm that I have read, understood, and agree to the terms outlined in this agreement.
Client or Authorized Representative Signature: ___________________________
Printed Name: ___________________________Date: __________________

NewBridge Support Representative Signature: ____________________________
Printed Name: ___________________________Date: __________________
This agreement becomes effective upon signature and remains valid until terminated by either
party with appropriate notice as outlined above.

Form Version: 2.0 | Last Updated: August 11,2025