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

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

Signature

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