Member Application Form

Connections Place is a Clubhouse model program accredited by Clubhouse International. We offer hope, encouragement and opportunities to people who live with mental illness. We provide a supportive environment that encourages participation and a sense of belonging, with a focus on individual strengths and talents, rather than illness.

Please complete this application form if you are interested in becoming a Connections Place member. Once you complete the form, click the submit button at the bottom.

Member Information

First name:

Last name:

Preferred Name:

Street 1:

Street 2:

City:

Province:

* Postal code: *

Home phone:

OK to call me here

Work phone:

OK to call me here

Cell phone:

OK to call me here

Email address:

Date of birth:

Income Information:

3. Receiving Clubhouse news and updates:

Referral Source:

Outreach Notes:

Primary Diagnosis of Mental Illness:

What kinds of email would you like to receive?

Health/Medical Contact Information

First name:

Last name:

Work phone:

* OK to call here

Relationship:

Family/Community Contact Information

Emergency Contact Information

First name:

Last name:

Home phone:

Work phone:

Cell phone:

Relationship:

Safety Information

To qualify for membership you must have a past or present primary diagnosis of mental illness. In order to maintain a safe environment, we are not able to offer membership to those who have a recent history of violent or aggressive behaviour. However, a history of violence does not necessarily mean you are not eligible for membership.

2. Receiving outreach calls and mail:

If yes, please briefly explain and indicate the year of the most recent incident:

Income Information

Housing Information:

Other - Please specify:

Housing Information

1. Having my photo published:

Other - Please specify:

Medical Conditions and/or Allergies

Please list any medical conditions and/or allergies:

Medications

Please list all medications:

Clubhouse Services

The Clubhouse offers services to assist you in reaching your goals and supporting your recovery process. What interests you in becoming a member? Place a tick beside the option(s) that interest you.

Other - Please specify:

Children under 18

Please list any children under 18:

Informed Consent

I understand that a history of violence does not necessarily mean I am not eligible for membership. I understand that my application is subject to Connections Place's Privacy Policy (available from our office upon request).

I Agree

Member Information

Health/Medical Contact Information

Family/Community Contact Information

1

2

3

4

Emergency Contact Information

Safety Information

Income Information

Housing Information

Medical Conditions and/or Allergies

Medications

Clubhouse Services

Children under 18

Informed Consent