Member Referral

Clubhouse Pro

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.

Agency, Unit, or Hospital : *

First Name : *

Last Name : *

Phone Number : *

Email Address : *

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.

Authorization Form (ROI).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.