Membership Application

Membership Eligibility

This form must be filled out and signed by healthcare practitioner/doctor such as Psychiatrists, Mental Health Care Provider, Physician, VRS or DOR Counselor.
California Clubhouse is a membership based social/vocational community for individuals 18 years and older with a mental health diagnosis. We require an application, eligibility form and an orientation to participate.

Eligibilty Form must be completed by Psychiatrists, Mental Health Care Provider, Physician, VRS or DOR Counselor.

All participation is voluntary and at no cost to members.
To be eligible for California Clubhouse programs, members need to live in San Mateo County*, be 18 years of age or older, and have a diagnosis of Schizophrenia Disorder, Schizoaffective Disorder, Bipolar Disorder, Major Depressive Disorder, Anxiety Disorder, PTSD or Depression.

All information will be kept confidential.

*If you do not reside in San Mateo County, connect with us via email or phone.
Potential Member Name:*

First NameLast Name
Date Of Birth:*

MonthDayYear
Date
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number:
Email:
example@example.com
Referral Source
Referrer Name

First NameLast Name
Referring Agency
Agency Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Mental Health Professional
Name of Mental Health Professional

First NameLast Name
Type of Mental Health Professional/Job Title
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Mental Health Diagnosis and Medications:
Mental Health Diagnosis*

Schizophrenia DisorderSchizoaffective DisorderBipolar DisorderMajor Depressive DisorderAnxiety DisorderPTSDOther
Current Medications:
Clubhouse Community Safety:

As part of our standards, we ask about recent history of violent behavior to ensure a safe environment for all members. Members with past accounts of violent behavior or criminal records may still be eligible for membership.
Does the prospective member pose a current and significant threat to the safety and security of the Clubhouse Community?

YesNo
If Yes, please explain:
Psychiatric History:
Date of last Psychiatric Hospitalization

MonthDayYear
Date
Length of Time
Precipitating Factors
Total Number of Psychiatric Hospitalizations
At What Age Did The Person Experience Their First Psychiatric Hospitalization?
Does the Prospective Member Participate in Mental Health Recovery Programs?

YesNo
If Yes, Which Programs?
Does the Prospective Member Have a History/Risk of Suicide Attempts?

YesNo
Does the Prospective Member Have a History of Alcohol or Drug Use?

YesNo
Additional Comments
Healthcare Practitioner or Doctor's Signature*

Clear
Signature Date:

MonthDayYear
Date
Should be Empty:

Membership Eligibility

Referral Source

Mental Health Professional

Mental Health Diagnosis and Medications:

Clubhouse Community Safety:

Psychiatric History: