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29378648A • 8-20
Psychiatric - Intensive Outpatient Program (IOP) (Please ensure your program meets criteria specied below
for the type of services you provide. Signature is required)
• A short-term structured treatment for psychiatric illness is provided by a multidisciplinary health care treatment team. The
treatment is more intensive than outpatient treatment but less intensive than partial hospital programming. Treatment
will include a minimum duration of 3 hours per treatment day and will not exceed 19 hours per week.Multidisciplinary
assessment with an individualized treatment plan which addresses psychological, social, medical, cognitive, and substance
use needs. This should include coordination of care with patient’s outpatient providers.
• Blood or urine drug screening is considered if clinical progress is not occurring or when substance misuse is suspected.
• Psychoeducation is provided.
• Structured clinical programming is provided.
• Goal-directed treatment plan. Goals are clear, achievable and time-limited with a focus on reduction of the symptoms
that led to admission.
• Prompt family or support system involvement is expected at every level of treatment plan development,
unless doing so is clinically contraindicated.
• Coordination of care with other clinicians, relevant to the treatment being provided, is documented.
• Linkage and/or coordination with the patient’s community resources with the goal of returning the patient to his/her
regular social environment as soon as possible, unless contraindicated. School contact should address Individualized
Educational Plan(s) as appropriate for school children.
• Treatment is individualized and not determined by a programmatic timeframe. It is expected that the focus will
be preparing the patient for adaptive functioning in the community setting.
• Discharge planning is initiated on the day of admission and includes coordination with family and community resources
to allow a smooth transition back to outpatient services, family integration, and continuation of the recovery process.
• Documentation standards include individualized progress notes in the patient’s record that clearly reect implementation
of the treatment plan and the patient’s response to the therapeutic intervention for all disorders treated, as well as
subsequent amendments to the plan.
I attest that the Institution/Facility below meets all of the above program criteria.
Name (Print or Type) Title
Signature Date (MM/DD/YYYY)
Please double check that the application is complete.
If you are having diculty submitting the form once completed, please send using one
of the following methods:
– Click on “File” at the top of your screen
– Click on “Save As”
– Save the completed form on your computer
– Attach the completed form to an email and send to email@example.com
• Fax: 701-282-1910
• Mail: 4510 13th Ave. S.
Fargo, ND 58121
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