IOP Enrollment/Referral Inquiry Form

Mindset Tacoma's Mental Health IOP (18+)

New Enrollment/Referral Inquiry

Thank you for your interest in our Intensive Outpatient Program (IOP). Please complete this inquiry form and a member of our team will reach out to you shortly.

Who would be receiving care?

Myself

Someone else (submitting on behalf of someone else)

First name

Last name

Preferred name (if different from your legal name)

Email address

Phone number

Date of birth

Month

Day

Year

Gender identity

IOP Enrollment/Referral Inquiry Form