Intensive Outpatient Program (IOP) Referral Form

Intensive Outpatient Program (IOP) Referral Form
Intensive Outpatient Programs (IOP) provides a step-up in support from outpatient treatment and provides group therapy, individual therapy, and medication management services. IOP occurs 3-4 days per week and runs approximately 9-12 weeks, depending on the program. If you have questions about our IOP programs, please contact (651) 313-8080 (option 4).

In network insurance: UBH/Medica, BCBS, PreferredOne, UCare, HealthPartners, Aetna, America’s PPO/HealthEZ, Tricare. Insurances that do not provide coverage for IOP services: MN MA (and PMAP) and Medicare.
Client Name *

First NameLast Name
Client Preferred Pronouns:*
Client Date of Birth*

MonthDayYear
Date
Select Preferred IOP Track*

DepressionDBT
Name of Insurance Company*
Client Phone Number*
Please enter a valid phone number.
Client Email*
example@example.com
What is the best time to contact client?*
How did you hear about us?*

Internet Search (Google)Friend or Family MemberAnother Provider (ie. Doctor, case manager)An online advertisement (Facebook/YouTube)Psychology TodayOther Media (i.e. radio or TV)NewsletterAt a Community Event (ie. resource fair, presentation)Other
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