Apply For Membership

JOIN US!

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

Estimated time to complete: 30 minutes

You may download the form, print our new member application and return it to us by regular mail, confidential fax, or drop it off at our physical location.

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.
WHAT YOU WILL NEED TO APPLY:
- Proof of Insurance (if you have it)
- Proof of ID (if you have it)
- Personal information
- Housing and transportation information
- Employment information
- Income Information
- Medical Information
- Provider Information
ELIGIBILITY
To be eligible for AIM Center membership an individual must:
- be interested in attending AIM Center, as membership is voluntary.
- have a Serious Mental Illness as a primary diagnosis.
- received mental health services in the past 12 months.
- be able to engage safely and independently in the clubhouse.
- be at least 18 years of age.
AIM Center, Inc. does not discriminate on the basis of race, color, religion, sex, age, national origin, veteran status, sexual orientation, gender identity, disability, or any other basis of discrimination prohibited by law.
ATTACHMENTS (OPTIONAL)

Please attach the following documents so that the membership team may process your application.
Please attach a copy of a government-issued photo ID:

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Please attach a current insurance card - front and back (required only if you are currently insured):

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YOUR INFORMATION
Name*

First NameLast Name
Preferred name, if other than your legal name
Preferred Pronouns
Date of Birth*

MonthDayYear
Social Security Number
Gender Identity
Sexual Orientation
Race/Ethnicity
Primary Language
Marital Status
Are you a Veteran?
CONTACT INFORMATION
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number
Please enter a valid phone number.
Alternative Phone Number
Please enter a valid phone number.
Email

Confirmation Emailexample@example.com
What is the best way for us to get in touch with you?
MENTAL AND PHYSICAL HEALTH INFORMATION
Primary Psychiatric Diagnosis (DMS V):

SchizophreniaSchizoaffectiveMajor Depressive DisorderBipolar
Other Mental Health Diagnosis:
Secondary Diagnosis:
Other Physical Health Conditions

Mobility ImpairmentDeaf/Hearing ImpairmentAsthmaSevere Allergic ReactionsNew Psychiatric MedicationBlind/Visual ImpairmentEmphysemaDiabetesEpilepsy/Seizure DisorderHypertension
Psychiatric Contact
Have you seen a mental health provider in the last 12 months?
Psychiatrist/Mental Health Provider
Agency
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long have you seen this provider?
Therapist Contact
Have you seen a therapist in the last 12 months?
Therapist Name
Agency
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long have you seen this therapist?
Primary Care Provider
Have you seen a primary care provider in the last 12 months?
Primary Care Provider Name
Agency
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long have you seen this provider?
GENERAL INFORMATION
Have you had a tour of the AIM Center?*
What is your main goal in joining AIM Center*
Why would AIM Center be a good place for you?
What challenges or barriers are keeping you from achieving your goals?
EMPLOYMENT
Are currently employed?
Have you ever worked for pay?
Have you worked in the last 12 months?
EDUCATION
Please select the highest academic level achieved
HOUSING
Current Housing Type*
Do minor children reside in your home?
Do you have a history of homelessness?
If yes, in the past 12 months?
Please explain any homelessness history
EMERGENCT CONTACT
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
Emergency Contact Relationship*
Emergency Contact Email
example@example.com
Emergency Contact Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your Mental Health/Psychiatrist Provider Contact
Psychiatrist/Mental Health Provider
Agency of Provider
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long have you seen this provider?
SIGNATURE & ACKNOWLEDGEMENT
I certify that all the information that I have provided is correct and accurate and I am offering this information to the AIM Center freely and without coercion:
Your Signature:*

Clear
Today's Date:

MonthDayYear
Should be Empty:

ELIGIBILITY

ATTACHMENTS (OPTIONAL)

YOUR INFORMATION

CONTACT INFORMATION

MENTAL AND PHYSICAL HEALTH INFORMATION

Psychiatric Contact

Therapist Contact

Primary Care Provider

GENERAL INFORMATION

EMPLOYMENT

EDUCATION

HOUSING

EMERGENCT CONTACT

Your Mental Health/Psychiatrist Provider Contact

SIGNATURE & ACKNOWLEDGEMENT