Intensive Outpatient (IOP) Application
  • Intensive Outpatient (IOP) Application

  • What is an intensive outpatient program (iop)?
    Our Intensive Outpatient Program is a higher level of care designed
    to build community and support systems, structure, coping skills, and
    address co-occurring substance use and mental health with
    evidence-based treatments.

    How is IOP Structured?

    • 12 weeks long with 36, 3-hour sessions
    • 3 group sessions per week
    • Initial Treatment Plan to guide experience & goals
    • Individual Therapy on an as-needed basis for additional support

    What are the goals of IOP?

    • Educating about Alcohol Use Disorder (AUD) and Substance Use Disorder (SUD), patterns and consequences of use, relapse risks, the treatment process, and types of mutual-support groups
    • Providing recovery, coping, and relapse prevention skills
    • Building recovery support systems, including the use of peer support services and mutual-support groups
    • Overcoming barriers to engaging in treatment and maintaining recovery Providing physical and psychological symptom management for AUD and SUD
    • Engaging families and providing education on AUD and SUDs, patterns and consequences of use, family dynamics, and treatment and recovery processes Providing emotional support and enhancing motivation
    • Attending to other health and psychosocial needs, including housing, vocational, financial assistance, and other medical needs

    Group Topics (not limited to)

    • Grief Boundaries
    • Relapse Cycle Triggers
    • Self-Care
    • Shame and Guilt
    • Timelines

    Modalities (not limited to)

    • Solution-Focused Brief Therapy
    • Dialectical Behavior Therapy
    • Matrix Model of Substance Use
    • Contingency Management
    • Group-Centric Activities during Psychoeducation

    IOP Support Team 

    • IOP coordinator & therapists
    • Licensed counselors experienced in guiding positive therapy activities through group and individual sessions
    • Certified peer recovery specialist
    • Certified training to provide additional support and care navigation assistance 
  • ADMINISTRATIVE AND PAYER AUTHORIZATION PACKAGE

    Client and Referral Demographics
  • Admission and Financial Status

  •  - -
  • LEGAL AND CONFIDENTIALITY DOCUMENTS

  • NOTICE OF PRIVACY PRACTICES

    Your Information. Your Rights. Our Responsibilities. 

    This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. 

    Your Rights 

    You have the right to: 


    • Get a copy of your health and claims records. 

    • Ask us to correct your medical record. 

    • Request confidential communications. 

    • Ask us to limit what we use or share. 

    • Get a list of those with whom we’ve shared your information. 

    • Get a copy of this privacy notice. 

    • Choose someone to act for you. 

    • File a complaint if you believe your privacy rights have been violated. 

     

    Your Choices 

    You have some choices in the way that we use & share information as we: 


    • Share information with your family, close friends, or others involved in your care. 

    • Share information in a disaster relief situation. 

    • Communicate through mobile and digital technologies. 

    • Marketing purposes and sell your information without with your written authorization. 

     

    Our uses and disclosures 

    We may use and share your information as we: 


    • Treat you. 

    • Run our organization. 

    • Bill for your services. 

    • Coordinate care among health care providers. 

    • Help with public health and safety issues. 

    • Do research. 

    • Comply with the law. 

    • Respond to organ and tissue donation requests. 

    • Address workers’ compensation, law enforcement, and other government requests 

    • Respond to lawsuits and legal actions 

     

    Your Rights 

    When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you. 

    Get a copy of your health record. 

    • You can ask to see or get a copy of your health records and any other health information we have about you. Ask us how to do this. 

    • We will provide a copy of your health information, usually within 30 calendar days of your request. We may charge a reasonable, cost-based fee. 


    Ask us to correct your health records. 

    • You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. 

    • We may say “no” to your request, but we’ll tell you why in writing within 60 calendar days. 


    Request confidential communications. 

    • You can ask us to contact you in a specific way (for example, home or office phone) or send mail to a different address. 

    • We will consider all reasonable requests and must say “yes” if you tell us you would be in danger if we do not. 


    Ask us to limit what we use or share. 

    • You can ask us not to use or share certain health information for treatment, payment, or our operations. 

    • We are not required to agree to your request, and we may say “no” if it would affect your care. 

    • If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. 

    • We will say “yes” unless a law requires us to share that information. 


    Get a list of those with whom we’ve shared information. 

    • You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. 

    • We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months. 


    Get a copy of this notice. 

    • You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly. 

    Choose someone to act for you. 

    • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. 

    • We will make sure the person has this authority and can act for you before we take any action. 


    File a complaint if you feel your rights are violated. 

    • You can complain if you feel we have violated your rights by contacting us. 

    • You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. 

    • We will not retaliate against you for filing a complaint. 


    Your Choices 

    For Certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. 

    In these cases, you have both the right and choice to tell us to: 

    • Share information with your family, close friends, or others involved in your care. 

    • Share information in a disaster relief situation. 

    • Share information with you through mobile and digital technologies (such as sending information to your email address or to your cell phone by text message or through a mobile app). 


    In these cases we never share your information unless you give us written permission: 

    • Marketing purposes. 

    • Sale of your information. 


    In the case of fundraising: 

    • We may contact you for fundraising efforts, but you can tell us not to contact you again. 


    Our Uses and Disclosures 

    How do we typically use or share your health information? We typically use or share your health information in the following ways: 

    Treat you
    We can use your health information and share it with other professionals who are treating you. Example: A doctor treating you for an injury asks another doctor about your overall health condition. 
    Run our organization
    We can use and disclose your information to run our organization, improve your care, and contact you when necessary. Example: We use health information about you to manage treatment and services. 
    Bill for your services
    We can use and share your health information to bill and get payment from health plans or other entities. Example: We give information about you to your health insurance plan so it will pay for your services. 

    How else can we use or share your health information? 

    We are allowed or required to share your information in other ways – usually in ways that contribute to public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html. 

    Help with public health and safety issues 

    • We can share health information about you for certain situations as: 

    - Preventing disease 

    - Helping with product recalls 

    - Reporting adverse reactions to medications 

    - Reporting suspected abuse, neglect, or domestic violence 

    - Preventing or reducing a serious threat to anyone’s health or safety 


    Do research 

    • We can use or share your information for health research. 


    Comply with the law 

    • We share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with the federal privacy law. 

    Respond to organ and tissue donation requests 

    • We can share health information about you with organ procurement organizations. 

    Work with a medical examiner or funeral director 

    • We can share health information with a coroner, medical examiner, or funeral director when an individual dies. 


    Address workers’ compensation, law enforcement, and other government requests 

    • We can use or share information about you: 

    - For workers’ compensation claims 

    - For law enforcement purposes or with a law enforcement official 

    - With health oversight agencies for activities authorized by law 

    - For special government functions such as military, national security, and presidential protective services 


    Respond to lawsuits and legal actions 

    • We can share information about you in response to a court or administrative order, or in response to a subpoena. 

    Additional restrictions on use and disclosure 

    • Certain federal and state laws may require greater privacy protections. Where applicable, we will follow the more stringent federal and state privacy laws regarding to the disclosures of health information. 


    Our Responsibilities 

    Recovery Soldiers Ministries (RSM), its employees, and its practices takes our patients’ right to privacy seriously. To provide you with your care, RSM creates and/or receives personal information about your health. This information comes from you, your physicians, health insurers, and other health care service providers. This information, called protected health information, can be oral, written, or electronic. 

    • We are required by law to maintain the privacy and security of your protected health information. 

    • We are required by law to ensure that third parties who assist with your treatment, or our requests for payment or health care operations maintain the privacy and security of your protected health information in the same way that we protect your information. 

    • We are also required by law to ensure that third parties who assist us with treatment, payment and operations abide by the instructions in our HIPAA Employee Confidentiality Agreement. 

    • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. 

    • We must follow the duties and privacy practices described in this notice and give you a copy of it. 

    • We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html. 


    Changes to the terms of this notice. 

    We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office. 

    Effective Date of this notice: June 2022 

    Last Revised on: October 2025

  • Powered by Jotform SignClear
  • HIPAA Information and Patient Privacy Consent

    Our Notice of Privacy Practices provides information about how we (“the Practice”) may use and disclose protected health information about you (aka “Patient”). The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. The terms of our Notice may change, and if so, you may obtain a revised copy by contacting our office. 

    You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement. 

    By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. Recovery Soldiers Ministries provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). 

    The patient understands that: 

    Protected health information may be disclosed or used for treatment, payment or health care operations. 
    All other disclosures by Recovery Soldiers Ministries will require specific authorization by you unless required by law. 
    Recovery Soldiers Ministries has a Notice of Privacy Practices and that the patient can review this Notice and receive a copy. 
    Recovery Soldiers Ministries reserves the right to change the Notice of Privacy Policies. The new policy will be available upon request from our office. 
    You have the right to restrict the uses of their information used for treatment, payment or operations, but the Practice does not have to agree to those restrictions.

  • Powered by Jotform SignClear
  • I furthermore give Recovery Soldiers Ministries authorization to disclose information about my program progress to my immediate family. This statement of consent is subject to revocation by the patient at any time, except to the extent that the ministry of person who is to make the disclosure has already acted in reliance on it.

  • Powered by Jotform SignClear
  • Media Consent Form

     

    Recovery Soldiers Ministries is pleased to participate in social media outlets such as Facebook, Instagram, YouTube, Google+, etc. Through these venues, we share pictures, updates, testimonies, and other inspiring and helpful information that may benefit our donors, partners, and families of those in the program. With the expressed permission of our program participants, we are pleased to share posts congratulating students on accomplishing their goals and completing the program.


    I give my consent to allow Recovery Soldiers Ministries to post updates, videos, or photographs of me on social media.

     

    I understand that RSM utilizes AV monitoring systems for the purposes of client, staff, and property safety and security. I acknowledge that I may be recorded while on the premises. I understand that these recordings may be reviewed by authorized personnel, including but not limited to, facility staff, management, and legal authorities as required by law or internal policy. I understand that these recordings will be stored securely and accessed only for legitimate purposes related to safety, security, incident investigation, quality assurance, and compliance. By participating in the program, I consent to this AV monitoring.

  • Powered by Jotform SignClear
  • Powered by Jotform SignClear
  • Powered by Jotform SignClear
  •  - -
  • Should be Empty: