Intake Form

Molly van Rijssen Expressive Counseling, LLC

Molly van Rijssen, LPC, ATR
LPC #4792; ATR #07-023

First Name(Required)

Last Name(Required)

Gender(Required)

Male

Female

Date(Required)

Email Address(Required)

Address(Required)

Home Phone Number

Office Phone Number

Cellphone Number

Date of Birth(Required)

Age(Required)

Referred by

Person and Number to Call in Emergency(Required)

Marital Status(Required)

Former/Present Marriage(s) (Years)

Spouse/Partner's Name

Age

Occupation

Children/Step/Grand (Name and Ages)

Siblings (Name and Ages)

Parents/Step-Parent(s)

Occupation/Position

Presenting Problem

Medical Doctors

Phone Number

Last Examination

Past/Present Medical Care

Past/Present Counseling/Psychotherapy/Mental Hospitals

Past/Present Drug/Alcohol Use/Abuse

Family History of Alcoholism, Mental Illness, Violence, Suicide