Referral Form (for Clinicians)

Client referral

At FOCUS Clubhouse our goal is to provide a safe haven for adults who suffer with mental illness. We are structured by a work-ordered day in units such as culinary, gardening, communications, community outreach, tutoring and housekeeping, to name a few. Working side by side with staff assists in fostering healthy relationships between peers and staff while providing a social atmosphere to learn everyday life skills and develop the confidence they need to encounter the real world. We are not a drop off center nor are we a clinical type facility. We are a place where equals come together and grow.

We appreciate your referrals. Please fill in your clients' name with email and/or phone and their diagnosis below.

**We follow all HIPAA laws and any transmission within this site is secure.

* Indicates required field

Client *

First

Last

Phone Number *

Email *

My client is diagnosed with: *

Comment *

The following is information regarding you, the referring clinician.

Name *

First

Last

Work Title *

Employer / Business *

Phone Number *

Email *

Submit