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 :
*
Potential member is homeless.
Street :
*
City :
*
State :
*
Zip :
*
County :
*
Mobile Number :
*
Alternate Number :
Email Address :
Insurance :
*
AARP
Medicaid
Other
Uninsured
Veterans Affairs
Secondary Insurance :
How did you hear about us :
*
Community Mental Health Center
Criminal Justice
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 : *
existing member
family
family physician
friend
Hunstman Mental Health Institute (HMHI) Park City
Other
Provo Canyon Behavioral Hospital
Psychiatric Nurse Practitioner
Psychiatrist MD
Summit Co Clubhouse
Therapist
Wasatch Behavioral Health- Case Manager
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
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? *
Park City
Additional Notes :
This Clubhouse may be required by Medicaid to obtain an Assessment and Treatment Plan on all referrals.