Member Referral

Clubhouse Pro

Refer A New Clubhouse Member

Complete the steps below to refer a new member.

Clubhouse Membership Criteria

18+ years of age
History of mental illness
Membership is open to anyone who does not pose a significant and current threat to the general safety of the Clubhouse Community

Who Are You Referring

First Name : *

Last Name : *

Alias :

Gender(s) : *

Race(s) :

Date of Birth : *

Potential member is homeless.

Street : *

City : *

State : *

Zip : *

County : *

Mobile Number : *

Alternate Number :

Email Address :

Insurance : *

Secondary Insurance :

How did you hear about us : *

Your Clubhouse may be required by Medicaid to obtain an Assessment and Treatment Plan on all referrals.

Who Is Submitting The Referral

Agency, Unit, or Hospital : *

First Name : *

Last Name : *

Phone Number : *

Email Address : *

Final Details

Upload Supporting Documents: (i.e. ROI, Mental Health Evaluation, Medications, etc.)

Members start date may be delayed without all requested documentation*.

You can upload multiple documents by selecting more than one file in the file explorer after "Browse" is selected.

Downloadable Forms

Clubhouse Referral Release of Information.docx

If no diagnosis please select 'Unknown' from the list below.

ICD10 Code:

Type:

Severity:

Diagnosis Date:

Please select the main reason(s) for referral: *

Education Housing Employment Health & Wellness Community Events Healthy Relationships and Self Worth Purpose & Confidence

Which clubhouse are you interested in attending? *

Additional Notes :

This Clubhouse may be required by Medicaid to obtain an Assessment and Treatment Plan on all referrals.

Please use signature pad below to sign off on referral:

Signer First Name : *

Signer Last Name : *