• Behavioral Health - Student Intake

  • Referrer (Person Filling Out Form)

  • v20260825

  • Format: (000) 000-0000.

  • Student Information

    Enter only information about student. 🚸 Parent / guardian info will be on the next page.
  • Format: (000) 000-0000.
  • Has student received counseling services from Trellus before?

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

  • Date of Birth*
     - -
  • Private Insurance Type*
  • Do you have an ID number?*
  • Browse Files
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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

  • Does student have internet at home?
  • What does student use to go on the internet?

  • Languages

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

    Secondary Language: {secondaryLanguage} {secondaryLanguageOther}

    English Skill Level: {englishSkill}

  • 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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