Intensive Outpatient Program Online Referral

By submitting this online referral form, you are consenting to the Intensive Outpatient Program staff contacting you. If you have questions about this form, or prefer to complete a referral over the phone, please call us at 563-589-2309.

I am seeking information and treatment for

MyselfA friend or family memberA patient or client I support

Your Information

First Name

Last Name

Phone Number

Email Address

Do we have permission to leave you a voicemail?

YesNoI'm not sure/unknown

Are you located in the Dubuque County Area?

YesNoI'm not sure/unknown

Where are you located?

Please list the full name and phone number of anyone who is addressing your brain health needs. Examples: Counselors, case managers, social workers, psychiatrists, nurse practitioners, primary care providers.

In your own words, what is your primary concern?

In your own words, what are your goals for treatment?

Participant Information

First Name

Last Name

Phone Number

Do we have permission to leave a voicemail on the participant's personal voicemail?

YesNoI'm not sure/unknown

Is the participant located in the Dubuque County Area?

YesNoI'm not sure/unknown

Where is the participant located?

Please list the full name and phone number of anyone who is addressing the participant's brain health needs. Examples: Counselors, case managers, social workers, psychiatrists, nurse practitioners, primary care providers.

What is the primary concern for seeking treatment? Please list symptoms, diagnoses, etc.

Is the referred participant aware of this referral?

YesNo

STOP!

STOP! Please stop this referral and inform the referred participant before continuing.

Referral Information

What is your relationship to the participant being referred to this program?

First Name

Last Name

Phone Number

Email Address

Would you like your email added to our newsletter email list? These emails are sent quarterly and include program updates, openings, and any important changes in the Intensive Outpatient Program.

YesNo

Please provide any additional information.

Insurance Information

Name of Insurance Provider

Additional Insurance Information

Informed Consent

This program’s estimated length of stay is 2-3-months. The program schedule is Monday’s Wednesday’s and Friday’s from 9:00 am to 11:50 am. All sessions are required unless approved ahead by staff.

Please check below if you understand the time requirements of this program.

I understand the program time requirements.

This Program is in person. The hospital and the IOP enforce all mask precautions. The Intensive Outpatient Program (IOP) continues to take the necessary safety measures. In May of 2020, the Intensive Outpatient Program moved to a larger office to maintain social distancing. Everyone entering the Hospital completes a health screening at the entrance of the hospital.

Please check below if you have been informed of safety expectations.

I have been informed of safety expectations.

Last Step

Please provide any additional information you believe would be helpful for the Intensive Outpatient Program treatment team to know.