Behavioral Health Intake Form

WE ARE CURRENTLY EXPERIENCING A HIGH VOLUME OF REFERRALS. OUR WAITLIST IS CURRENTLY 3 MONTHS BEFORE YOU WILL RECEIVE YOUR FIRST APPOINTMENT. IF YOU’D LIKE TO BE ADDED TO THE WAITLIST, PLEASE COMPLETE THE FORM BELOW, HOWEVER YOU WILL NOT RECEIVE AN IMMEDIATE RESPONSE. IF YOU WOULD LIKE TO EXPLORE OTHER OPTIONS IN THE COMMUNITY, PLEASE VISIT HTTPS://MENTALHEALTH.CHICAGO.GOV/. THANK YOU AND WE HOPE TO BE ABLE TO SUPPORT YOU SOON.

Contact Information for the person filling this form

Relationship to the person seeking services

Who are you completing this form for?

Full Name

Phone Number

If person needing services is a minor, parent/guardian name.

Parent First Name

Parent Last Name

Information about the person needing services

First Name

Last Name

Preferred Name

Pronouns

Email address to contact client

Phone Number

Birthdate

Street Address

City

Zip Code

Have you been to Trellus before for counseling services?

YesNo

Health Insurance?

Insurance Type

Medicaid/Insurance Id Number

Upload Insurance Card

Best Call Back Number

Best Call Back Time

Primary Language

Do you need a translator?

Translator Language

Referring Provider (Organization) & Staff Name (If applicable)

Reason for Referral (Please provide a brief description of behavioral, social or emotional or environmental concerns).

Prior DSM diagnoses (if applicable)

School Name (if child)

Current grade level/highest level of education

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 Asian Human Services intake staff. This Staff will directly work with you to match you with appropriate care across Asian Human Service network of services. Information you provide in this form is confidential.

Contact Information