SeaMar Community Health Center
Intensive Outpatient Program
1920 100th St SE, Suite C, Everett, WA 98208
Tel: (425)609-5505 Fax: (425)609-5506
Intensive Outpatient Program Referral Form
Referring Clinician:___________________________________ Clinician Phone:___________________
Referring Agency:____________________________________ Referral Date:_____________________
Consumer Name:______________________________ Consumer ID:______________ DOB:________
Consumer Address:___________________________________ Consumer Phone:_________________
Current Diagnosis: Axis I______________________________ Axis II___________________________
Axis III________________________________ Axis IV__________________________ GAF_________
Most Recent LOCUS: Score_______________ Level______________ Date administered___________
1. Describe services consumer is currently receiving:
2. Describe current symptoms/level of functioning:
3. Describe treatments/services tried in the past, dates, outcomes (please be as specific as possible):
4. Describe consumer’s history of psychiatric hospitalization or contact with legal system:
5. Please describe history and current risk of harm to self and/or others:
6. Describe need for IOP services:
The individual experiences significant functional impairments due to mental illness as
demonstrated by 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 as evidenced by consistent difficulty with the following:
__caring for personal business affairs or budgeting
__obtaining medical, legal, or housing services
__recognizing and avoiding common dangers or hazards to self and possessions
__meeting nutritional needs of self/family
__maintaining personal hygiene or washing clothes
__childcare tasks and responsibilities
__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).
The individual experiences continuous high service needs due to mental illness as demonstrated
by:
__Moderate to high use of psychiatric hospitals (In the past year- 2 or more admissions of more than 72
hours duration, or 30 or more total days, or a single stay of 21+ days).
__Persistent, recurrent, or severe major symptoms.
__Co-occurring substance use disorder of significant duration (6+ months).
__Recent and/or criminal justice involvement.
__Significant difficulty meeting basic survival needs, currently in substandard housing, or homeless.
__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 able to live in a more
independent living situation if intensive services are provided.
__Requiring a residential placement if more intensive services are not available.
__History of: __medication non-adherence and/or __treatment non-compliance
Consumer/Guardian Signature:_______________________________________ Date:_______________
Clinician Signature:________________________________________________ Date:_______________
Supervisor Signature:______________________________________________ Date:_______________
Please fax completed referral form to (425)609-5506. Should you have any questions regarding
the application process, please contact Jonathan Goodman at (425)609-5503 or email to
jonathangoodman@seamarchc.org.
IOP use only:
__Approved
__Denied Comments:_____________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Signature:________________________________________________________ Date:_______________