(or affix label)
Date
Referring Clinician
Client’s current outpatient program: Referring Clinician phone:
Client Address:
Client funding: WMIP
Current Diagnoses:
Axis I
NSMHA If NSMHA, specify authorization end date:
Axis II
Axis III
Axis IV
Axis V Current LOCUS:
Describe the services this individual is currently receiving:
Describe current problems and risk factors associated with each Axis (above):
Start date of clients current episode of care:
Has the client had previous episodes of care? Yes No If yes, describe circumstances around past discharges:
Describe history of psychiatric hospitalization (please be as specific as possible).
Clinical/Intensive Outpatient Program Referral (Reviews/Teams) (8/28/13) Page 1 of 3 502f

Describe history of contact with the legal system (please be as specific as possible).
Describe client’s ability and willingness to be part of a community team of resources that would wrap around the client.
Has the clinician discussed this referral with the client? Are they receptive to the IOP model?
Explain how the client is expected to benefit from IOP (i.e. a program with intense frequency of contacts primarily on an outreach basis). Please be as specific as possible.
What do you anticipate to be the length of stay in IOP for this client?
What would you expect the outcomes to be for this client? In other words, how would we know it is time for the individual to step down from IOP services into standard outpatient services?
1.
2.
3.
4.
Admission Criteria (Mark all that apply)
The client has a current LOCUS/CALOCUS level of 3 or higher
AND
The client experiences continuous high service needs due to mental illness as demonstrated by at least two of the following:
Moderate to high use of psychiatric hospitals (e.g. in the past year, two or more admissions of more than 72 hours duration, or 30 or more total days, or a single stay of 21 or more days)
Persistent, recurrent, or severe major symptoms
Recent and/or recurrent criminal justice involvement
Significant difficulty meeting basic survival needs, currently residing in substandard housing, or homelessness
At imminent risk of becoming homeless (repeated evictions and/or currently on eviction notice)
Residing in a supervised community residence and clinically assessed to be abel to live in a more independent living situation if intensive services are provided.
Requiring more intensive services to preclude residential placement.
History of medication or treatment non-compliance.
AND
The client experiences significant functional impairments due to mental illness as demonstrated by at least one of the following conditions:
Significant difficulty in consistently performing the range of practical daily living tasks required for basic functioning at home and/or in the community.
Persistent or recurrent difficulty performing age appropriate daily living tasks except with significant support or assistance from others such as friends, family, or relatives.
Significant difficulty maintaining important and/or supportive relationships with others.
Significant difficulty maintaining a safe living situation (e.g. excessive hoarding; consistently unsanitary conditions due to uncollected garbage, food scraps and other waste material).
Skagit County: Tel. 360-419-3500 Fax. 360-419-3599 Snohomish County: Tel. 425-349-7481 Fax. 425-349-7223
Clinical/Intensive Outpatient Program Referral (Reviews/Teams) (8/28/13) Page 2 of 3 502f

(or affix label)
Date Referral Received:
Referral is:
Approved
Start date
Support staff: special episode created
Response due by:
1 st IOP appointment on:
(14 calendar days)
Global alert posted
Denied
Reason ~
Program at capacity, no openings
Client meets exclusionary criteria:
Client requires 24 hour supervision for health and safety reasons
Client requires more restrictive environment such as hospital, nursing home, or supervised residential placement
Client does not appear to meet admission criteria (explain)
Referral source notified of outcome on:
IOP Program Contact Date
Clinical/Intensive Outpatient Program Referral (Reviews/Teams) (8/28/13) Page 3 of 3 502f