Membership Application Form for Clubhouse International

  • Beacon Clubhouse Member Application

    Beacon Clubhouse is based on “the Clubhouse Model of Psychosocial Rehabilitation” which is an evidence-based practice as defined by the United States Substance Abuse and Mental Health Services Administration (SAMHSA).

  • Beacon Clubhouse is unable to accept individuals whose primary diagnosis is dementia, traumatic brain injury, or developmental disability, including Autism Spectrum Disorders.

    Potential members must have a primary diagnosis of mental illness.

  • It is desirable for potential members to have a monthly income, shelter, food, and appropriate medical/psychiatric care, as we do not have the resources to work on these areas at the outset of membership. It is preferred that potential members have their own cell phone and/or email address. All potential members must live in St Louis County.


    Beacon Clubhouse is avidly interested in recruiting members who are able to participate side-by-side with other members and staff to run Beacon Clubhouse. We are also interested in employment and/or educational goals individuals may have.


    All personal information is kept confidential. Information such as age, gender, race, income, current housing situation, etc. is collected so it can be analyzed and used for fundraising purposes.

  • Is someone assisting you with filling out this application? *
  • Format: (000) 000-0000.
  • Do you consent to having text messages sent to this phone number? If this is not a cell phone, select No. *
  • How do you prefer to be contacted?*

  • Please enter the address where you would like to receive mail in regards to your membership application process and other member only postcards.
     

  • Are you currently working with a case manager or social worker?*
  • Are you currently working with a therapist? *
  • Are you currently working with a psychiatrist?*
  • Date of Birth*
     - -
  • Gender*
  • Do you have a business card from your Provider, Psychiatrist, Case Manager, or Therapist you wish to upload?
  • What is your primary diagnosis? *

  • We will verify your diagnosis with your provider after the application has been submitted. 
     

  • Have you been hospitalized within the last 3 years for mental health symptoms?
  • What is your current living situation? *
  • How will you be coming to Beacon Clubhouse
  • Current Employment Status
  • Employment History
  • What are your sources of financial support? (Check all that apply). *
  • What is your monthly income? *
  • Highest level of education completed
  • Are you currently enrolled in school?
  • Are you interested in returning to school?
  • What is your current Legal History? *
  • Have you ever been convicted of a sexual offense? *
  • Do you have a history of alcohol and/or drug misuse?

  • Beacon Clubhouse offers opportunities to discover and use your strengths, talents, and abilities. All work at Beacon is intended to assist you in enhancing your self-worth, purpose, and self-confidence.

    Please rate the following from 1 to 5 stars with 1 being not important to me at this time to 5 being the most important to me at this time.

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