Ohio - IOP Services Screening Application

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.
Preparer Email
example@example.com
Date of Application

MonthDayYear
Date
Client Information
Applicant's Full Name
Date of Birth

MonthDayYear
Date
Social Security Number
Primary Phone Number
Client Email Address
Current Residential Address
Referral Source: (Include case manager name and contact info if applicable)
Insurance plan name and ID number
Are you currently in another SUD program?
If so, which one?
Are you graduating from the program or being released?
If you are being released, what is the reason for the release?
Are you a previous client of Reach?
What is the primary reason you are seeking Intensive Outpatient Program (IOP) services at this time?
If you are leaving against staff advise, why?
Is the current program in agreement of transfer?
Please list all diagnosed physical medical conditions. **No mental health diagnosis**.
Currently pregnant? (Female)
Have you been seen by OB/GYN? (Female)
Who is your PCP?
Please list your medications and the reason for taking: (Gabapentin is only allowed for documented seizure disorders and severe neuropathy and must be supported).
Do you require any medical equipment or technological interventions? If yes, please elaborate.
Do you have any physical limitations and need a bottom bunk? If yes, please elaborate.
Do you have any mental health diagnoses?
If yes, what the diagnoses?
Who is your mental health provider? Please provide the contact information.
Have you previously participated in any mental health or substance abuse treatment programs (Inpatient, Residential, PHP, IOP, or standard Outpatient)? If yes, Where
Are you seeking MAT services?
Are you currently using MAT now? (no oral forms of Buprenorphine, Suboxone or Subutex is permitted. These clients that wish to continue will need to establish on Sublocade PRIOR to arrival)
What is the date of your last MAT service?

MonthDayYear
Date
Who is your MAT provider? (Include contact info)
How long was your longest periods of sobriety?
What date was last use?

MonthDayYear
Date
What substance was used?
Method of Use? Ex: Snorted, oral, smoking, drinking
Do you have any upcoming medical/psychiatric appointments within the next 30 days from your arrival date? If so, when and where?
Are you currently in jail or prison?
If yes, what is your charge?
What is your expected release date?

MonthDayYear
Date
Are you on probation or parole? If so, what county and who is your assigned PO?
Do you have any upcoming appointment with parole/probation within the next 30 days from your arrival date?? If so, when and is it in-person or telephone?
What were your past convictions?
Are you aware of any warrants out for your arrest?
If yes, Through what county
Are you a registered sex offender?
Have you been convicted of arson?
Have you been convicted of sex trafficking?
Please list any important information on yes answers:
Do you have any scheduled court appearances in the next 30 days ? If yes, please list the date and county.
Do you have any children under the age of 18?
Do you have any open CPS cases at this time?
If yes, CPS caseworker name and phone number
Do you have a job? If yes, what position, shift, and who is the employer? Please note: REACH requires clients to remain unemployed during the first 30 days of programming. Exceptions may be considered on a case-by-case basis.
Do you have transportation? If needing transport, include full address. Please note: Transport is not guaranteed, if Reach can not transport, insurance will need to provide ride
Do you have food stamps, If so what County
When can you start services with REACH?

MonthDayYear
Date
What location are you wanting?
Intake Processing- Office Use Only
- Date of Arrival?
  
  MonthDayYear
  Date
- Sex offender registry checked:
- Arson registry checked:
- Warrant search performed:
- Insurance verified:
- Was OARRS check by Staff
- Reason for admission declination:
  
  Other
- Please elaborate if other:
- Additional notes:
- Approved/Denied By:
Should be Empty:

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

Client Information

Intake Processing- Office Use Only