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Home Intake Assessment

At SterlingHaven, families entrust us with their most cherished loved ones.

  • Care You Can Trust

The SterlingHaven Difference

At SterlingHaven Human Services, we do care differently. We believe that true support for older adults comes from continuity, familiarity, and meaningful relationships—not rotating staff or rushed shifts. Our caregivers are carefully selected professionals who choose consistency over convenience. They learn your loved one’s routines, preferences, and communication style, becoming a familiar, trusted presence rather than a revolving door. This approach creates calm homes, safer routines, and deeper connections. Every SterlingHaven caregiver is thoroughly screened, trained, and supported, including:

  • Pennsylvania State Background Check
  • Federal Background Check when required
  • Multiple professional reference checks
  • Verification of credentials and education
  • Ongoing training and supervision

They are fully insured and bonded, ensuring accountability, safety, and consistency of care. Above all, our clients can expect to be treated with dignity, kindness, and respect at every visit. With SterlingHaven, families can trust that their loved ones are supported by skilled professionals.

  • SterlingHaven Human Services

Payment & Coverage

At SterlingHaven Human Services, access to quality care should never be limited by financial confusion or unnecessary barriers. We work with families to make payment straightforward, transparent, and manageable from the start. We accept the following payment options:

  • State Assistance Programs
  • Private Insurance
  • Long-Term Care Insurance
  • Home and Community-Based Waiver Programs
  • Veterans’ Benefits
  • Private Pay (Cash)

Our team assists with coverage verification and payment coordination, ensuring you understand your options and can move forward.

  • Assessment Form

Client Intake & Initial Assessment

This form helps us understand each client’s unique needs, preferences, routines, and care requirements.It allows our team to create a personalized care approach.

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1. CONSUMER & INTAKE INFORMATION
Assessment:
Assessor:
2. REASON FOR REFERRAL / GOALS / PREFERENCES
Primary reason for home care / current concerns:
Consumer goals, routines, preferences, cultural/language needs, and important do/don't instructions:
3. FUNCTIONAL NEEDS — CHECK ALL THAT APPLY
ADLs
Mobility
IADLs
Support
4. HEALTH / SAFETY SNAPSHOT
Medications in home:
Reminder only needed:
Cognition:
Communication:
Recent falls/ER/hospitalization:
Explain:
Skin/wound concerns:
Oxygen/medical equipment:

*If needs appear skilled, unstable, or outside the agency/DCW scope, escalate to the Administrator/RN/appropriate provider before assignment.

5. HOME ENVIRONMENT & EMERGENCY PLANNING
Lives:
Stairs:
Bathroom safety equipment:
Fire/smoke/CO detectors noted:
6. REQUESTED SERVICE PLAN — INITIAL
Requested Services:
Schedule — Days: Start: End: Est. hrs/week:
Assistance Level:
Caregiver Match — Preferences/considerations:
7. INTAKE DETERMINATION / FOLLOW-UP
Required follow-up before start of care:
Notes/risks/special instructions:
8. ACKNOWLEDGMENT

The consumer/representative participated in identifying needs, preferences, and requested services. This intake assessment supports service planning and does not replace the required pre-service consumer information packet, service agreement/plan, or other required disclosures.

Compliance reference: Pennsylvania DOH, 28 Pa. Code Chapter 611, including §611.57 consumer protections; agency policy and payer/program requirements may impose additional documentation.

Thank you

The intake assessment has been submitted successfully.