This form is a sample of an agreement between an elderly or disabled client and a Caregiver who operates as an independent contractor and provides personnel to assist Client to live at home and to have as much control over the home environment and life as possible under the circumstances. Caregiver's personnel also assist Client with the activities of daily living, scheduling medication, assistance with mobility, accompanying Client on errands and appointments, and such other services as agreed between Client and Caregiver.
In this agreement, Client waives damages for simple negligence of Caregiver, but not gross negligence or misconduct that is intentional or criminal in nature. Courts generally will not enforce waivers of this type of misconduct since such a waiver would be deemed to be against public policy because it would encourage dangerous and illegal behavior.
Caregiver Form Sample For Ages 1.5-5 Scoring In Clark
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State:
Multi-State
County:
Clark
Control #:
US-00458BG
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Response format 3-point Likert scale (0 = “Absent”, 1 = “Occurs sometimes”, 2 = “Occurs often”). Strengths: The CBCL is a valid and reliable measure which is sensitive to change in short interventions.
Assessment Tools The Conners 4rd Edition (Conners 4®) Conners 4® is an assessment tool designed to measure a range of behaviours in children aged six to 18. ASEBA Child Behaviour Checklist (CBCL) ... Vineland Adaptive Behaviour Scales (Vineland-3) ... Adaptive Behaviour Assessment System (ABAS-III)
Any score that falls below the 93rd percentile is considered normal, scores between the 93–97th percentile are borderline clinical, and any score above the 97th percentile are in the clinical range.
CBCL/1.5-5 - Child Behavior Checklist for Ages 1.5-5. The CBCL/1.5-5 obtains caregivers' ratings of 99 problem items. Items are scored on the following syndrome scales: Emotionally Reactive, Anxious/Depressed, Somatic Complaints, Withdrawn, Attention Problems, Aggressive Behavior, and Sleep Problems.
'Clinically significant' elevations are indicated by T-scores ≥ 64 on the broadband scales, and ≥ 70 on the syndrome scales. 'Borderline' elevations range from 60–63 and 65–69 on the broadband and syndrome scales, respectively.
Ing to the normative data of the CBCL, a t-score ≤ 59 indicates non-clinical symptoms, a t-score between 60 and 64 indicates that the child is at risk for problem behaviors, and a t-score ≥ 65 indicates clinical symptoms (for demographical, cognitive, and psychopathological measures of participants, see Table 1).
The CBCL measures factors such as depression, somatic complaints, hyperactivity, aggressiveness, sexual behavior, anxiety, and delinquent behavior.
Caregiver Reaction Assessment The CRA consists of 24 items with 5 subscales: self-esteem (SE), lack of family support (LFS), impact on finance (IF), impact on schedule (IS), and impact on health (IH), with Likert response format options from 1 to 5 (strongly disagree to strongly agree). Five items are reverse scored.
The measure contains five dimensions: personal and social restrictions, physical and emotional health, economic costs, value investment in caregiving, and the perception of the care recipient as provocateur. Items are scored on a 4-point scale (strongly agree, agree, disagree, strongly disagree).
'Clinically significant' elevations are indicated by T-scores ≥ 64 on the broadband scales, and ≥ 70 on the syndrome scales. 'Borderline' elevations range from 60–63 and 65–69 on the broadband and syndrome scales, respectively.
