Membership Application

18 years or older
Diagnosis of Serious Mental Illness (SMI refers to mental, behavioral, or emotional disorders that cause significant functional impairment, substantially interfering with or limiting major life activities.)
Currently seeing a mental health provider

When you come to the Clubhouse, we will also have you fill out a form stating that all of the following are true:

I meet the qualifications above.
I am able to safely and independently engage in the Clubhouse.
I understand that I can leave the building at any time without intervention.
I understand that I will not be supervised at all times.
I understand that all members must maintain safe and non-threatening behaviors while at the Clubhouse.
I understand that the Clubhouse is based on a “Work Ordered Day” model. This means that members and staff work together to complete the work of the clubhouse while making steps towards their goals.
I understand that membership and participation are voluntary.
I understand that when I attend the Clubhouse, I attend with the intent to participate to the best of my abilities.
I believe that mental health recovery is possible.
I understand that at AIM we are dedicated to justice, equity, and inclusivity and it is reflected in a commitment to treat everyone with kindness and respect.
I understand that I am not a member until I have completed Blast Off Orientation and cannot access the clubhouse until then.

To apply for membership, complete the form below as thoroughly as possible. This form is confidential and compliant with all HIPAA regulations.

Please note: Unless you are a current threat to Clubhouse safety, your legal history and substance use history does not determine eligibility for becoming a member of the AIM Center.

If preferred, you are also welcome to download a paper application and return it in person or via mail, fax, or secure email.

Email:

membership@aimcenterinc.org

Fax:

(423) 648-9135

Mail:

ATTN: MEMBERSHIP

AIM CENTER

472 W MLK BLVD

CHATTANOOGA, TN 37402

All fields marked with * are required and must be filled.

Date:

Date

Name:

First NameMiddle NameLast Name

Preferred Name: (if applicable)

Birthdate:

Social Security Number:

Gender Identity:

Sex at Birth:

Preferred Pronouns:

Other

Address

Street Address

Street Address Line 2

City/State/Zip:

Street Address

Street Address Line 2

City, State

Postal / Zip Code

Move In Date:

Enter your best guess for the date you started living at your current address.

Phone Number:

Applicant's phone numberFormat: (000) 000-0000.

Other Phone:

Format: (000) 000-0000.

Email Address:

example@example.com

Race/Ethnicity: (select all that apply)

Primary Language:

Religion:

Veteran?

Marital Status

Highest Grade Completed:

Employment Status:

Do you have any of the following? (Check all that apply)

Other

Name of responsible party:

Conservator or POA Name

Contact Number:

Format: (000) 000-0000.

Email:

example@example.com

Qualifications for membership:

When you come to the Clubhouse, we will also have you fill out a form stating that all of the following are true:

Demographics:

Emergency Contact:

Entitlements:

Alcohol/Substance Use Info:

Current Hospital Episodes:

Medical Info:

Referred By: