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 :
Prefer Not To Say
Black or African American
Hispanic or Latino
American Indian or Alaska Native
Date of Birth :
Mobile Number :
Alternate Number :
Email Address :
Secondary Insurance :
How did you hear about us :
Community Mental Health Center
Private Clinics/Private Therapist
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 : *
Provo Canyon Behavioral Hospital
Psychiatric Nurse Practitioner
Summit Co Clubhouse
Wasatch Behavioral Health- Case Manager
Enter Other :
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.
Members Included in Count But Don.docx
If no diagnosis please select 'Unknown' from the list below.
Please select the main reason(s) for referral: *
Health & Wellness
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.