IOP Intake Inquiry
For referring providers, families, or self referrals. Our IOP coordinator will call within one business day to discuss availability and next steps.
Your Name
*
First Name
Last Name
Your Relationship to Patient
*
Please Select
I am the patient
Parent or guardian
Spouse or partner
Other family member
Referring provider
Referring agency or facility
School counselor or social worker
Other
Your Email
*
example@example.com
Your Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Patient Name
*
Patient Age
*
Which IOP Track?
*
Please Select
Adult IOP (Monday Wednesday Thursday 9AM to 2PM)
Adolescent IOP (Monday Tuesday Thursday 3PM to 6:30PM)
Not sure please advise
Insurance
*
Please Select
Medicare
Aetna
Blue Cross Blue Shield
Cigna
United Healthcare
Self pay
Other
Presenting Concerns (check all that apply)
*
Depression
Anxiety or panic
Suicidal thoughts current or recent
Self harm behaviors
Substance use
Trauma or PTSD
Bipolar disorder
OCD
Emotional dysregulation
Relationship or family conflict
Life stressors or transitions
Recent psychiatric hospitalization
Transitioning from higher level of care
Other
Timeline when do you need to start?
*
Please Select
This week urgent
Within 2 weeks
Within 1 month
Flexible just gathering info
How did you hear about us?
Please Select
Google search
Referred by a doctor
Referred by therapist
Referred by hospital or psychiatric facility
Referred by school
Friend or family
Insurance directory
Other
Tell us more about what's going on
If you or the person you are referring is experiencing current suicidal thoughts or a crisis, please call the 988 Suicide and Crisis Lifeline before submitting this form.
Submit Inquiry
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