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) :
Black or African-American
White
Hispanic or Latino
American Indian or Alaska Native
Native Hawaiian
Pacific Islander
Asian
Other
Date of Birth :
*
Street :
*
City :
*
State :
*
Zip :
*
County :
*
Mobile Number :
*
Alternate Number :
Email Address :
Insurance :
*
Medicaid Expansion
No Medicaid Funding
Traditional Medicaid
Secondary Insurance :
Healthy U
Molina
Select Health
Steward
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 *
The Clubhouse is required by Medicaid to obtain an Assessment and Treatment Plan on all referrals.
Who Is Submitting The Referral
Agency, Unit, or Hospital : *
4th Street
Adult Probation and Parole
alliance house walk in
Alpha Counseling
Angie S.
Aspen Ridge Counseling Center
BAART Programs
Behavioral Health Office
Best Practice Counseling
Canyon Rim Care Center
Capitol City Psychiatry
Center for Christian Therapy
Center for Counseling Excellence
City Creek Post Acute
Clinical Consultants
Collective Recovery Center
Community Mental Health Center
Cornerstone Counseling Center
Cottonwood Psychiatry & Counseling
Criminal Justice System
Davis Behavioral Health
DBT Network of Utah
DCFS
Decision Point Counseling
Development Counseling Services
Discover Center
Exodus Healthcare Network
family counseling center
First Step House
Fortitude
Friend
GCS, Inc. (Fiduciary)
Health First Family Medicine
Highland Care Center
Highland Ridge Hospital
Highland Spring Specialty Clinic
Holding Out Help
Hopeful Beginnings
Huntsman Mental Health
I'm Mac's Stepmom. I can have a formal referral sent.
Impact Mental Health
In Tune Counseling & Coaching
Integrative Therapies
Intensive Outpatient Clinic - University of Utah
Intercept Behavioral Health
Intermountain Healthcare
Intermountain LDS Hospital
Island Doctors
John Green
Jordan Valley Medical Center
Latino Behavioral Health
LDS Hospital-Adult In-Patient Psychiatric
Lotus Center
Meaningful Life Counseling
Mental Health America
Mental Wellness Centers
Molina Healthcare insurance - case manager
Mountain States Counseling Center
Mountain View Hospital Behavioral Health
NAMI
New Roads Behavioral Health
New Season Bountiful Treatment Center
Northeastern Counseling Center
Odyssey House
Odyssey House Lighthouse
Odyssey House Martindale Clinic
Ogden Regional Medical Center
OptumCare
Other
outpatient psychiatrist
Parent
PATH Behavioral Healthcare
Polizzi Clinic
Primary Children's Hospital
Private Clinic/Private Mental Health Professional
Project Connection CTI program
Psychiatric and Behavioral Solutions
Refugee & Immigration Center Asian Association o Utah
Rural Clinic-Elko
Sacred Circle Healthcare
Sally Burgin LCSW
salt lake behavorial health
Self
Sister
South Point Counseling Services
Sovegna
St Marks Family Medicine Residency
St. Mark's Hospital
Strive Psychiatry
Sugar House Health Center
Summit Community Counseling
Summit County Clubhouse and Sundance Counseling
Sundance Behavioral Resources
The Lotus Center
The OCD and Anxiety Treatment Center
The Road Home
Therapist
U of U 5 West Unit
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University Neuropsychiatric Institute (UNI)
University of Utah 5W
University of Utah Greenwood Family Practice
University of Utah Madsen Health Center Family Practice
University of Utah Student Health Center
Unknown
Utah Behavior Services
Utah Department of Health
Utah Healing Center
Utah State Hospital
VA Medical Center
Valley Behavioral Health
Veterans Administration
Vocational Rehabilitation
Volunteer of America Youth Resource Center
Volunteers of America ACT team
Volunteers of Americal Cornerstone Counseling
VR Downtown
Wasatch Mental Health
Wasatch Pediatrics - Southpoint
Wellness Recovery Center
Westridge Academy
Woodland Park Care Center
YWCA Utah
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
Authorization Form (ROI).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? *
Salt Lake City
Additional Notes :
This Clubhouse may be required by Medicaid to obtain an Assessment and Treatment Plan on all referrals.