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We are currently open and fully operational. Enjoy your appointment in office or over secure video chat. Call us at (724) 910-1665 to schedule today.

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Healing Broken Hearts

Counseling Services

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Home
Learn More
- About Us
- Testimonials
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Forms
Contact Us

Client Intake Form

Client intake form for Healing Broken Hearts

Step 1 of 5

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Personal Information
Your Name
First Last
Name of Parent/Legal Guardian (if under 18)
First Last
Address
Street Address Address Line 2 City State ZIP Code
What type of insurance will you be using? (or if you intend to pay in cash, please write cash)
Home Phone
May we leave a message?
- Yes
- No
Cell/Work/Other Phone
May we leave a message?
- Yes
- No
Email
May we leave a message?
- Yes
- No
Age:
Gender
Date of Birth
Marital Status
- Never Married
- Domestic Partnership
- Married
- Separated
- Divorced
- Widowed
Referred By (if any):

In Case Of Emergency
Name of friend/relative/spouse
First Last
Relationship to patient
Home phone number
Work phone number

History
Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)?
- Yes
- No
Are you currently taking any prescription medication?
- Yes
- No

If yes, please list

General and Mental Health Information
How would you rate your current physical health?
- Poor
- Unsatisfactory
- Satisfactory
- Good
- Very good
Please describe any specific health problems you are currently experiencing
How would you rate your current sleeping habits
- Poor
- Unsatisfactory
- Satisfactory
- Good
- Very good
Please describe any specific sleep problems you are currently experiencing
Please describe any difficulties you experience with your appetite or eating problems
If yes, for approximately how long?
Are you currently experiencing anxiety, panic attacks or have any phobias?
- Yes
- No
If yes, when did you begin experiencing this?
Are you currently experiencing any chronic pain?
- Yes
- No
If yes, please describe
Do you drink alcohol more than once a week?
- Yes
- No
How often do you engage in recreational drug use?
- Daily
- Weekly
- Monthly
- Infrequently
- Never
Are you currently in a romantic relationship?
- Yes
- No
If yes, for how long?
On a scale of 1-10, how would you rate your relationship?
What significant life changes or stressful events have you experienced recently?

Additional Information
Are you currently employed?
- Yes
- No
If yes, what is your current employment situation?
Do you enjoy your work? Is there anything stressful about your current work?
Do you consider yourself to be spiritual or religious?
- Yes
- No
If yes, describe your faith or belief
What do you consider to be some of your strengths?
What do you consider to be some of your weakness?
What would you like to accomplish out of your time in therapy?
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Healing Broken Hearts

Counseling Services

Dr. Angie Huey, PHD.

(724) 910-1665

The Atrium Building

665 Philadelphia Street

Suite 104

Indiana, PA 15701

Links:

Home
About Us
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Contact Us

Services:

Adolescent Counseling
Family Counseling
Individual Counseling
Marriage Counseling