Herron Solutions Intensive Outpatient Program (IOP) Screening

This short form helps you decide if an Intensive Outpatient Program (IOP) might be a good fit. It is not a diagnosis. If you are in crisis, call 988 or 911.

This form must ONLY be completed by prospective participant

PLEASE DO NOT PRINT

Participants attending via telehealth must be in a private and confidential location for the full 3-hour 15 minute session w/scheduled breaks. They must remain present the entire time with their camera on at all times. Eating, drinking, smoking, or vaping during group is not permitted. No other individuals may be present in the space during the session.

Date:

Full Name (Listed on insurance)

Phone Number (Please note personal or message)

Email

Are you over 18

What city would you like to receive services?

Are you a New Mexico resident?

What type of insurance do you currently have?

Section 1-Your Main Concerns (last 30 days unless noted)

Alcohol or drug use causing problems

Using more than intended or unable to cut down

Cravings/urges or relapse risk

Withdrawal symptoms when cutting back/stopping

Depression, anxiety, trauma, or mood swings

Sleep problems, energy or concentration issues

Legal, school, work, or family problems related to use or mental health

I was in detox, ER, or hospital in the past 90 days

Section 2-Safety (today)

I feel safe and do not plan to hurt myself or others

I have thoughts of self-harm or feel unsafe (tell us—there is help)

I can stay substance-free during services

I need help to reduce/stop use safely

Section 3-Daily Life & Supports

I can get to appointments (ride, bus, telehealth)

I need help with transport/tech

I have some support (family/friends/peer)

I would like help building support

My home/recovery setting is mostly stable

My setting has risks or stress I need help with

Section 4-Readiness & Time: IOP is a structured program each week (Adults: 9 hours; Youth: 6 hours).

I can attend this many hours each week

I’m unsure but want to discuss options

I am willing to join group therapy (up to 15 people)

I prefer mostly individual/family sessions

Section 5-Your Goals: What would you like to change or improve? (check all that apply)

Reduce or stop alcohol/drug use

Learn coping skills for cravings/urges

Improve mood, anxiety, trauma recovery

Strengthen family/relationships

Stay in school/work or get back on track

Build a healthier routine and support network

Other

Brief History

I have had counseling/therapy before

I have been in IOP/PHP/residential before

I take prescribed medications for mental health or recovery

I am currently on medication assisted treatment (MAT) with a medical professional

Quick Fit Check: If you check many items in Sections 1–5 and can commit the weekly time, IOP may be a good fit. A clinician will complete a full ASAM 2.1 assessment to confirm.

I believe I need more than weekly counseling right now

I want structured support several days each week

I am not in immediate medical/psychiatric crisis requiring hospital-level care

I am willing to follow a recovery/safety plan

Preferences & Access

Evenings work best

Mornings work best

Telehealth works for me

In-person works for me

Language/cultural needs

Accessibility needs (mobility, hearing, vision, etc.)

Consent to Contact-If you want us to reach out, add your contact preference:

Okay to call (able to leave a message)

Okay to text

Okay to email

Best time to call

Participants attending via telehealth must be in a private and confidential location for the full 3-hour 15 minute session w/scheduled breaks. They must remain present the entire time with their camera on at all times. Eating, drinking, smoking, or vaping during group is not permitted. No other individuals may be present in the space during the session.

By checking this box I understand the rules for Virtual IOP.

Signature

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