Inspire/Linden Oaks IOP-Light Eligibility Criteria
CONFIDENTIAL REFERRAL
Inspire/Linden Oaks IOP-Light Eligibility Criteria
Student Name / Click or tap here to enter text.High School / Click or tap here to enter text.
Student age/grade level / Click or tap here to enter text. / Student ID / Click or tap here to enter text.
Student Primary Language / Click or tap here to enter text. / Family Primary Language / Click or tap here to enter text.
Parent Contact Name: / Click or tap here to enter text. / Primary Phone Parent: / Click or tap here to enter text.
Referring Agent [Name/Phone #] / Name: Click or tap here to enter text. Phone: Click or tap here to enter text.
/ Motivation for Engagement
☐ / Motivated to engage in treatment. Willingness to engage mental health assistance. Able to actively participate in treatment interventions.
☐ / Minimal use of drug or alcohol use or no discernable pattern. (Sobriety while in program required)
Student’s reported level of motivation to participate in IOP.
1
No motivation
☐ / 2
Minimal motivation
☐ / 3
Mild Motivation
☐ / 4
Moderate motivation
☐ / 5
Confirmed motivation
☐
Collateral information:
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/ Level of Functioning [Typical candidates have a full-scale I.Q. of 85 or above]☐ / Deterioration in functioning – increased anxiety/ increased irritability, increased sadness, decreased appetite, increased or decreased sleep, loss of interest in formerly pleasurable activities. Minimum impairment with level of functioning in the job, home or school environment.
☐ / Moderate to Severe Levels of Anxiety which create difficulties with functioning – daily or weekly panic attacks hyperventilating, social anxiety, and problem solving deficits.
☐ / Student remains able to function independently in home environment but could benefit from psychoeducational intervention to increase level of coping skills.
☐ / Discernible and moderate impairment impacting student’s ability to engage in school/work and/or behave in an inappropriate fashion.
☐ / Decreased concentration, inability to focus, easily overwhelmed or frustrated.
Severity of symptoms that relate to level of functioning.
1
No Impairment
☐ / 2
Minimal Impairment
☐ / 3
Mild Impairment
☐ / 4
Moderate Impairment☐ / 5
Severe Impairment
☐
Collateral information:
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/ Suicidal/Homicidal Ideation☐ / No reported active suicidal ideations. Vague thoughts, however no plan, intent or access to means.
☐ / No reported active homicidal ideations
☐ / Past suicidal ideations or past suicidal attempts which did not require medical intervention or assistance.
☐ / Reasons for living outweigh reasons for dying. Able to articulate a deterrent or mitigating factor such as life aspirations, religion or family. Requests assistance to eliminate thoughts.
☐ / Reports fear, anxiety or is upset about vague and/or recurrent suicidal thoughts. Requests assistance to eliminate thoughts.
Severity of symptoms that relate to suicidal/homicidal ideation.
1
No Impairment
☐ / 2
Minimal Impairment
☐ / 3
Mild Impairment
☐ / 4
Moderate Impairment☐ / 5
Severe Impairment
☐
Collateral information:
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/ Contextual Factors☐ / Mood/functioning impacted by recent loss or losses within the past month.
☐ / Support Systems in place – Family, Friends, Peers. Willing to engage support systems if needed.
☐ / Oriented to Person, Place, Time, and Situation. Able to fully participate in treatment modalities.
☐ / Limited Support Systems in place; Family, Friends, Peers deny student’s need for treatment assistance. Conflictual relationships in the family of origin.
Impact of pertinent/mitigating contextual factors.
1
No Impact
☐ / 2
Minimal Impact
☐ / 3
Mild Impact
☐ / 4
Moderate Impact
☐ / 5
Severe Impact
☐
Collateral information:
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Do not write in this box - Program Facilitator Notes:1
Somewhat
impaired/eligible / 2
Mildly impaired /eligible / 3
Impaired/eligible / 4
Moderately impaired/review / 5
Severe/ not eligible