• 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.

  • Aspire House 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.

    The application form can be found here.

    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 Aspire House programs, members need to be 18 years of age or older and have a mental health diagnosis.

    All information will be kept confidential.

  • Date Of Birth:*
     - -
  • Format: (000) 000-0000.

  • Referral Source

  • Format: (000) 000-0000.

  • Mental Health Professional

  • Format: (000) 000-0000.

  • Mental Health Diagnosis and Medications:

  • Mental Health Diagnosis*

  • 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?*

  • Psychiatric History:

  • Date of last Psychiatric Hospitalization*
     - -
  • Does the Prospective Member Participate in Mental Health Recovery Programs?*
  • Does the Prospective Member Have a History/Risk of Suicide Attempts?*
  • Does the Prospective Member Have a History of Alcohol or Drug Use?*
  • Signature Date:
     - -
  • Should be Empty: