• Behavioral Health Intake

  • v20260825

  • Who is the Person Needing Services?*

  • Referrer (Person Filling Out Form)

  • Format: (000) 000-0000.

  • Person Needing Services

  • Have you received counseling services from Trellus before?

  • Date of birth is {dobDisplay}. If this is not correct, please fix.

  • Date of Birth*
     - -

  • Enter only information about Person Needing Services below.
    🚸 Parent / guardian info will be on the next page.

  • Format: (000) 000-0000.
  • How do you want to communicate with Trellus?
  • Best days & times for counseling sessions
    Rows
  • Are dates & times flexible?
  • Private Insurance Type*
  • Do you have an ID number?*
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  • 🚸 Parent / Guardian Information🚸

  • Format: (000) 000-0000.
  • 🚸 How does parent / guardian want to communicate with Trellus?

  • Future Programs & Services

    Your answers help us plan for the future & make recommendations to help you today!

  • Name: {clientName}

    DOB: {dobDisplay}

    Gender Identity: {genderIdentity}

  • Communications

  • Email: {clientEmail}

    Phone: {clientPhone}

    Preference: {commPref}

  • Housing

  • Address: {address}

  • Internet Access

  • Do you have internet at home or where you are staying?
  • What do you use to go on the internet?

  • Languages

  • Language most comfortable speaking: {language} {languageOther}

    Secondary Language: {secondaryLanguage} {secondaryLanguageOther}

    English Skill Level: {englishSkill}

  • Education & Employment

  • Family Services

  • Do you have young children?

  • Consent

  • The above information provided by you is necessary for starting your intake process. By checking this box, you acknowledge that you understand the information provided above will be accessible by Trellus intake staff. This Staff will directly work with you to match you with appropriate care across Trellus network of services. Information you provide in this form is confidential.

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