Depression 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 4 days per week and runs approximately 9 weeks. If you have questions about our IOP programs, please contact (651) 529-8670 (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

Date

Select Preferred IOP Track

Name of Insurance Company (Note: any MA, Medicare/Medicaid, and PMAP plans do not cover the program)

Client Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Client Email

example@example.com

What is the best time to contact client?

How did you hear about us?