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) :
*
Male
Female
Transgender
Prefer Not To Say
Non-Binary
Race(s) :
American Indian
American Indian or Alaska Native, Caucasian
American Indian, Asian
American Indian, Black or African American
Asian
Asian, Black or African American
Asian, Caucasian
Black or African American
Caucasian
Declined
Filipino
Other Race
White
Hispanic/Latino
Date of Birth :
*
Potential member is homeless.
Street :
*
City :
*
State :
*
Zip :
*
County :
*
Mobile Number :
*
Alternate Number :
Email Address :
Insurance :
*
Medicaid
Medicare
Other
Private Insurance
Uninsured
Secondary Insurance :
How did you hear about us :
*
Community Mental Health Center
Criminal Justice System
Current/Former Members
Family
Hospital
Other
Private Clinics/Private Therapist
Self-Referral
Veterans Administration
Vocational Rehabilitation
Please enter other way *
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 : *
AbsoluteCare
ACT/PACT
American Psychiatric Group
Apex Counseling Center
Balance Point Wellness, LLC
Baltimore Crisis Response, Inc.
Benjamin Israel, MD
Bon Secours Baltimore Health System
Change Health Systems
Chase Brexton Health Services
Complete Wellness
CounterPoint Health Services
Criminal Justice System
Developing Wellness Solutions
Dr. Angela Brantley, MD. (301) 717-0204
Families First Counseling and Psychiatry
Focus Point Behavioral Health
Fresh Start Clubhouse, Ann Arbor, MI
GBMC Healthcare
Generation Changes, LLC
Harbor City Unlimited PRP
Hawn Therapy
Health Care for the Homeless
Huber Rehabilitation Services
Jai Medical Center
JCS
Johns Hopkins (other department)
Johns Hopkins Bayview Medical Center
Johns Hopkins Hospital Community Psychiatry
Johns Hopkins Hospital Inpatient Psychiatry
Johns Hopkins Hospital Psychiatric ED
Joshi and Merchant
Kaiser Permanente
Kim's Affordable Home Care
Laureate Psychiatric Hospital Tulsa, OK
Legacy Healing Center
Levindale PHP
LifeBridge Health
Live Free Therapy LLC
Loyola Clinical Centers
Mackay Behavioral Health Services LLC
Make Believe LLC
Man Alive, Inc
Marian House
Maryland Psychiatric Research Center (MPRC)
Mayor’s Office of Homeless Services
MedStar Franklin Square
MedStar Harbor Hospital Inpatient Psychiatry
MedStar Harbor Hospital Outpatient Psychiatry
MedStar Harbor Hospital Psychiatric ED
MedStar Union Memorial Hospital (Inpatient)
MedStar Union Memorial Hospital Counseling Center
MedStar Union Memorial Hospital IOP
MedStar Union Memorial Hospital PHP
Mercy Medical Center
Metro F.A.C.T.S.
Mindoula Health
Molding Minds, LLC
Mountain Manor Treatment Center
North Ave. Mission
Northwest Hospital
Optimum Health Systems Inc
Optimum Health Systems, Inc.
Other Hospital
Other Outpatient/PHP/IOP Clinic
Other Private Practice
Other Substance Use Rehabilitation Program
Overcare Health Services
Paths For Families
People Encouraging People
Plains Area Mental Health Center
Powell Recovery Center
Precision Mental Health
Private Practice
Psych Associates of Maryland
Resonance Behavioral Health, LLC
Robert Littman, MD
Rogers Behavioral Health
SELF
Shepherd’s Clinic
Sheppard Pratt Health System (Day Hospital/PHP)
Sheppard Pratt Health System (Outpatient)
Sheppard Pratt Health System Inpatient Psychiatry
Sinai Hospital (Inpatient)
Sinai Hospital: Adult Outpatient Services
Sound Wellness Center
Spring Grove Hospital
Springfield Hospital Center
St. Agnes Hospital
The Goode Practice
The Mandala Center
The Therapy Collective
Thrive Behavioral Health
Total Health Care
Transformation Healthcare, Inc
Transformations/Northeast Health Services
Transforming Lives Counseling Services
Truecare Behavioral Health Systems, Inc.
UM Older Adult Clinic
UMMC Carruthers Clinic
UMMS Walter P. Carter Clinic
Umoja Collective
University Counseling Center
University of Maryland Medical Center ED
University of Maryland Medical Center Inpatient Psychiatry
University of Maryland St Joseph Medical Center
Veterans Administration
Villa Maria -- Fallstaff
Walter Reed National Military Medical Center
Willow Branch Therapy
Enter Other :
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:
Primary
Additional
Provisional
Severity:
Low
Medium
High
Diagnosis Date:
Add
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? *
B'More Clubhouse
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 :
*