Fountain House

Membership Application Form

Eligibility

To be eligible for membership an applicant must:
  1. be interested in attending Fountain House, as membership is voluntary.
  2. have a primary presenting problem associated with severe and persistent mental illness.
  3. be able to get to Fountain House.
  4. not pose a threat to our community.
  5. be at least 16 years of age.

  6. "The Clubhouse has control over its acceptance of new members"
    - Standard #2, International Standards for Clubhouse Programs, Clubhouse International

Fountain House 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

Required

Accepted file types: .pdf, .doc, .docx, .jpg

Maximum file size: 7 megabytes

Prospective Member

Address

Who is recommending you?

Why Fountain House?

Housing

Income

Enter monthly amounts in any categories that apply

Demographic Info

Ethnicity (check all that apply)

Education Level

(check all that apply)
School Attended
Years
Major
Did you Graduate?
test

Employment History


Please list all employment. Be sure to include the most recent and longest job.
Start Date
End Date
Employer
Title
Type of work
Hourly wage
Hours per week

Medical Alerts

(check all that apply)

Psychiatric/NP Contact

Therapist Contact

Medical Contact

Emergency Contacts

Medical Insurance

Medication Information

Please list all medications you are currently taking with respective names, dosage, and frequency.
Medication Name
Dosage
Frequency

Psychiatric Hospitalizations

Please list all hospitalizations beginning with the first. Be sure to indicate the most recent.
1
2
3
4
5
6
7
8
9
10

Substance Abuse History

Name of Substance
Date Started
Last Use

Legal History

CAGE-AID Questionnaire

The following is a questionnaire, required by one of our funding sources. Please note that your answers to these questions do not affect your acceptance to Fountain House.

When thinking about drug use, include drug use and use of prescription drug use other than prescribed.

Further Info

Signature

Application Submission

It is very important that all components of this application are absolutely complete. Any missing or incomplete components will, unfortunately, delay the application process.

Please allow the Membership Team approximately two weeks to review applications.
Please contact the Membership Office at (212) 582-0340 x240 with any questions. Thank you for applying to Fountain House.