• Leo worked with me while he attended PT school. While undertaking a very rigorous course of study, he always had time to help me. At first he assisted with activities of daily living, but as we got better acquainted, he also helped me with riding my handcycle among other things. Throughout our time together, he demonstrated not only a willingness but also an eagerness to learn what I was struggling with and find ways to help me solve those problems. For me, getting to ride my handcycle regularly is a huge boost to my physical and mental well being. Leo understood that and made it happen. Then when he moved away, he even found a replacement. It is a rare thing to find someone who uses their time and talents to help others in such a direct way, but that is what Leo does. I'm sure he would love to help others in any way he can.

Jacobs Transfers and Mobility Support is a sole-provider service. As such, I reserve the right to determine client availability based on my current schedule, location, and commute feasibility.

Decisions regarding new client intake are made solely on the basis of logistical capacity and are not a reflection of need, condition, or identity.

Jacobs Transfers and Mobility Support provides non-medical, non-therapeutic assistance including respite care, mobility support, transfers, and activities of daily living. While I am a licensed physical therapist, these services are not provided under my physical therapy license and are not intended to replace physical therapy, occupational therapy, or medical care.

Respite Care Liability Waiver and Service Agreement

Client Name: ____________________________________(“Client”)
Date of Birth: ___________
Date: ____________________

Independent Respite Care Provider: Jacobs Transfers and Mobility Support (“Provider”)

1. Nature of Services

Client understands that the services provided under this agreement include assistance with non-medical daily activities such as transfers, toileting, mobility, transportation, basic exercise support, babysitting and recreational companionship. These services are offered as private respite care and are not clinical or therapeutic in nature.

Client acknowledges that:

• These services are not medical treatment.

• These services are not physical therapy.

• Provider is not operating under his physical therapist license for the purpose of these services.

• These services are not affiliated with any employer or any healthcare organization.

• Client shall pay provider $__________ for each session or instance of service.

2. Assumption of Risk

Client understands that participating in daily care activities (e.g., physical transfers, walking assistance, exercise) carries certain inherent risks, including (but not limited to) falls, strains, or other unintended injuries. Client voluntarily assumes full responsibility for any and all risks, injuries, or damages that may occur during the course of care.

3. Emergency Care Clause

In the event of a medical emergency, Provider will call 911 and contact the emergency contact listed below. Client understands that while Provider is not providing medical care, he is CPR-certified and may initiate CPR or basic life support measures, if necessary, until emergency responders arrive.

Emergency Contact Name & Number: ____________________________________

4. Release of Liability

By signing this form, Client agrees to waive, release, and hold harmless Provider and its employees, managers, and members from any and all liability, claims, or causes of action, including personal injury, property damage, or other loss, arising out of or related to the services provided, except in cases of gross negligence or willful misconduct. Notwithstanding anything to the contrary, the liability of the Provider for any claim arising out of or related to this agreement, whether in contract, tort, or otherwise, shall be limited to the total fees paid by the client to the Provider.

5. Acknowledgment and Consent

Client certifies that:

• Client has read and understood this waiver and agreement.

• Client agrees to the terms and conditions outlined above.

• Client is signing this agreement voluntarily and understands that it is legally binding.

Client (or Legal Guardian) Signature: ____________________________
Printed Name: _______________________
Date: ____________________

Service Provider Signature: ____________________________
Printed Name: Leo Jacobs
Date: ____________________