Clubhouse Pro
Refer A New Clubhouse Member
Complete the steps below to refer a new member.
Clubhouse Membership Criteria
18+ years of age
History of mental illness
Membership is open to anyone who does not pose a significant and current threat to the general safety of the Clubhouse Community
Who Are You Referring
First Name :
*
Last Name :
*
Alias :
Gender(s) :
*
Male
Female
Transgender
Prefer Not To Disclose
Non-Binary
Two Spirit
Race(s) :
Black or African American
White
Hispanic or Latino
American Indian or Alaska Native
Native Hawaiian
Pacific Islander
Asian
Other
Asian Indian
Date of Birth :
*
Potential member is homeless.
Street :
*
City :
*
State :
*
Zip :
*
County :
*
Mobile Number :
*
Alternate Number :
Email Address :
Insurance :
*
Medicaid Expansion
No Medicaid Funding
Traditional Medicaid
Secondary Insurance :
Molina
How did you hear about us :
*
Community Mental Health Center
Criminal Justice
Current/Former Members
Family
Hospital
Other
Private Clinics/Private Therapist
Self-Referral
Veterans Administration
Vocational Rehabilitation
Please enter other way *
Your Clubhouse may be required by Medicaid to obtain an Assessment and Treatment Plan on all referrals.
Who Is Submitting The Referral
Agency, Unit, or Hospital : *
Case Manager
Community Mental Health Center
Compass Health
Criminal Justice System
Information and referral specialist
Lake Whatcom Treatment
LifeLine Connections
Mental Health Court
Mental Wellness Centers
Other
Peacehealth Medical
Prismatic Counseling, PLLC, Port Orchard
Private Clinic/Private Mental Health Professional
Road2Home Winter Homeless Shelter
SeaMar
Self
Sunrise Services
Therapist
Unity Care Northwest
Vocational Rehabilitation
Whatcom County Health and Community Services - GRACE
Whatcom Family Medicine
Enter Other :
First Name : *
Last Name : *
Phone Number : *
Email Address : *
Final Details
Upload Supporting Documents:
(i.e. ROI, Mental Health Evaluation, Medications, etc.)
Members start date may be delayed without all requested documentation*.
You can upload multiple documents by selecting more than one file in the file explorer after "Browse" is selected.
Downloadable Forms
CORS Referral Form - Original.docx
Whatcom Clubhouse Provider Referral.docx
Drop in policy.docx
If no diagnosis please select 'Unknown' from the list below.
ICD10 Code:
?
Type:
Primary
Additional
Provisional
Severity:
Low
Medium
High
Diagnosis Date:
Add
Please select the main reason(s) for referral: *
Education
Housing
Employment
Health & Wellness
Community Events
Healthy RelationShips and Self Worth
Purpose & Confidence
Which clubhouse are you interested in attending? *
Bellingham
Additional Notes :
This Clubhouse may be required by Medicaid to obtain an Assessment and Treatment Plan on all referrals.