• R.E.A.C.H for Tomorrow: IOP Services Screening Application

    Please complete this form accurately to screen for eligibility and placement in our Intensive Outpatient Program (IOP) services.
  • Date of Application*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Client Information

  • 💬 Have Questions about Reach?

    Our virtual Intake Coordinator, Chandra, can answer questions about REACH services, eligibility, insurance, housing, program requirements, and the intake process.

    Please return to this intake form after chatting with Chandra to complete your application.
     
     
     

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • How were you referred to REACH for Tomorrow?*
  • What type of insurance do you have?*
  • Which Medicaid plan do you have?*
  • What is the name of your insurance company?*
  • Has your caseworker or current program staff confirmed the transfer?*
  • Do you currently have any diagnosed physical health conditions?*
  • Do you currently have a Primary Care Provider (PCP)?*
  • Do you currently take medications? (OTC or prescriptions)*
  • Do you currently require any medical equipment or assistive devices?*
  • Do you have any physical limitations or mobility concerns that may require accommodations?*
  • Have you ever been diagnosed with a mental health condition?*
  • Are you currently receiving mental health services?*
  • Format: (000) 000-0000.
  • Have you previously participated in any mental health or substance abuse treatment programs (Inpatient, Residential, PHP, IOP, or standard Outpatient)*
  • What type(s) of treatment have you previously received?*
  • Which MAT medication are you currently receiving?*
  • When was your most recent MAT dose or appointment?*
     - -
    2 digit month, 2 digit day, 4 digit year
  • What was the date of your most recent substance use?*
     - -
    2 digit month, 2 digit day, 4 digit year
  • What substance(s) did you use most recently?*
  • How did you use the substance(s)?*
  • Do you have any upcoming medical/psychiatric appointments within the next 30 days from your arrival date?*
  • What is your expected release date?*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Are you currently on probation or parole?
  • Are you aware of any warrants out for your arrest?*

  • Applicants with a confirmed history or registry match involving arson, a sex offense, or a sex trafficking-related offense are not eligible for admission to REACH for Tomorrow and will be automatically denied.

     

  • Do you have any scheduled court appearances in the next 30 days ? *
  • Are you currently employed?*
  • Do you have transportation to REACH for Tomorrow for admission into the program?*
  • Do you need assistance arranging transportation to REACH for Tomorrow?*
  • Do you currently receive SNAP (food assistance) benefits?*
  • When can you start services with REACH?*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Intake Processing- Office Use Only

    • Intake Processing- Office Use Only 
    • Date of Arrival?
       - -
      2 digit month, 2 digit day, 4 digit year
    • Sex offender registry checked:
    • Arson registry checked:
    • Warrant search performed:
    • Insurance verified:
    • Was OARRS check by Staff
    • Reason for admission declination:
  • Should be Empty: