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.
YesNo
Full Name*

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
YesNo
Phone CallText MessageEmail
Please enter the address where you would like to receive mail in regards to your membership application process and other member only postcards.
Mailing Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
YesNo
YesNo
YesNo
Please list their names and agencies, as well as approximately how long you have been working with them.
Date of Birth*

MonthDayYear
Date
MaleFemaleTransgenderNonbinaryTwo-SpiritOtherPrefer not to say
Preferred Pronouns
Race/Ethnicity*
YesNo
DepressionBipolar DisorderSchizophreniaPTSDPersonality DisorderAnxietyAlcohol/ Substance AbuseTraumatic Brain Injury/ DementiaDevelopmental/ Cognitive DisabilityAutism Spectrum Disorder/ Asperger's SyndromeOther
We will verify your diagnosis with your provider after the application has been submitted.
YesNo
How did you hear about Beacon Clubhouse?
RentOwnTreatment CenterShelterHomelessGroup Home (Community-Based Residential Facility)Friend or Family MemberOther
Public TransportationSelf (i.e. Drive, Walk)ParatransitFriend/Family MemberOther
Part-time employmentFull-time employmentUnemployedRetiredStay-at-home parent (or caretaker)StudentDisabledOther
Never EmployedIntermittent Employment (Major gaps in employment)Stable Employment (Minimal gaps in employment)
Paid EmploymentFamilySSISSDIUnemployment InsuranceChild SupportW2NoneOther
No IncomeLess than $1000 per month$1000-$1500 per month$1500-$2000 per month$2000-$2500 per monthMore than $2500
Some High SchoolHigh School DiplomaGED/HSEDSome CollegeAssociates DegreeBachelor's DegreeMaster's DegreeDoctorateProfessional Degree
YesNo
YesNo
Never ConvictedCurrently on ProbationCurrently on ParoleCurrently on Deferred ProsecutionConvicted of a FelonyConvicted of a Misdemeanor
YesNo
AlcoholDrugs (prescription or illegal)BothNone
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.
Paid Employment *
Education/ Vocational program in the community *
Socializing *
Computer skill development *
Answering PhonesCashieringWorking with people/Customer ServicePreparing mealsFilingData entryMeal planningJournalism/WritingPublic speakingBook keeping/AccountingBlogging/VloggingSocial Media ManagementOther
What else are you interested in?
Why are you interested in becoming a Beacon Clubhouse member?
Is there anything else you would like us to know about you?
If you have any documents to upload you can drop them here

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Beacon Clubhouse Member Application