FOCUS Clubhouse
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PRELIMINARY membership application
Please note: Safety is paramount in any environment, not only for the staff but for our members. Membership is free of charge and while we welcome everyone, we do wish to stress bullying, violence, sexual harassment, unbecoming conduct, etc. is NOT TOLERATED. Please read the rules and regulations and abide by them to promote a harmonious clubhouse for everyone.
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Name
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First
Last
Gender
*
Male
Female
Prefer not to say
Age
*
Phone Number
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Email
*
Are you diagnosed with a mental illness?
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Yes
No
Inquiring for friend or loved one diagnosed with mental illness.
Do you
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drive yourself
take the bus
ride with friends
Are you employed?
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No
Full Time
Part Time
Self-employed
Have you ever been convicted of a violent or a sexual crime?
*
Yes
No
If so, please explain.
*
Are you on probation or parole?
*
No
Probation
Parole
Work release
Are you in substance abuse counseling or a program for substance abuse?
*
No
Yes
Why are you interested in FOCUS Clubhouse?
*
Additional Comment
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Submit
HOME
ABOUT US
Daily Working Units
UPCOMING EVENTS
Previous Events
MEDIA
GALLERY
ONE MAN'S VISION
Referral Form (for Clinicians)
MEMBERSHIP
Board Blogs and News
BUY A BRICK DONATION
Chitimacha Louisiana Open
SOLA Giving Day
DONATE
RESOURCES
FAQ
Stats on Mental Illness
SENIOR COVID-19 CARE
CLUBHOUSE INTERNATIONAL STANDARDS
Find a Clubhouse
CONTACT
