To Whom It May Concern



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Fountain House Bronx is dedicated to the recovery of men and women with mental illness by providing opportunities for our members to live, work and learn, while contributing their talents through a community of mutual support.

To Whom It May Concern:


To be considered for membership, the following must be submitted:
1). A Fountain House Bronx Membership Application

2). A detailed psychosocial summary

3). A detailed psychiatric assessment

4). Copies of all Health Insurance cards



Note: All documents described above must have been written within the

last 90 days.

It is helpful when all four of these components are submitted together. Also, please complete and return the attached Substance Abuse Questionaire with your documents.
Please note that we do not accept referrals for housing.
If you have a question or need assistance in any way, please contact the Membership Office at (718) 742-9884, Ext. 18.
Application information can be sent via fax to (718) 742-9867 or by mail to:
Fountain House Bronx

Attn: Membership Office

564 Walton Avenue

Bronx, NY 10451


Thank You,

The Membership Team

Rev: 6/2015

Fountain House Bronx Membership Application

The Fountain House Bronx vision is that people with mental illness everywhere achieve their potential and are respected as

co-workers, neighbors and friends.

Fountain House Bronx - a working community - offers people living with mental illness

a sense of belonging and the opportunity to form relationships,

so they can take the vital steps toward mental health. At Fountain House Bronx, members & staff work together in the running of the program. Members volunteer their time in various areas and,

together with staff, ensure that the organization is operating smoothly and efficiently.

It is by working side by side that relationships between and among members and staff are developed. Through these relationships and the meaningful participation in Fountain House Bronx work, members build skills, develop a sense of purpose, and strive towards achieving their individual goals.

To be eligible for membership an applicant must:




  1. be interested in attending Fountain House Bronx, 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.

The Clubhouse has control over its acceptance of new members” Standard #2, International Standards for Clubhouse Programs, ICCD




Prospective Member
First: MI: Last:_________________________________________

DOB: SSN:_______-_______-___________ Gender:______________________________

Place of Birth:______________________________________

Address

Street:_______________________________________________________________Apt:_________________

City:__________________________________State:__________________________Zip:_________________

Phone:________________________________County:_____________________________________________

How long have you resided here?______________________________________________________________

Email Address: ___________________________________________________________________________




Who is recommending you?

Name: Agency:______________________________________

Phone: Type of Agency:_______________________________

How long have you known this person?_______________________________________________________

Email Address: _________________________________________________________________________

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Why would Fountain House Bronx be a good place for you? _________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________


rectangle 9 Please check here if you have had a tour of Fountain House Bronx.

Date of tour: ___/___/___



autoshape 17

Current Housing Type (circle one)
1). Own Home/ Apartment (Non-subsidized) 8). Supervised Housing (Part-time Supervision)

2). Home of Family Member 9). Foster Care

3). Rooming/ Boarding House, Hotel 10). Psychiatric Hospital

4). SRO (Temporary) 11). Nursing Home

5). Supported Apt. (Subsidized) 12). Prison/ Jail

6). 24 Hr. Supervised Housing 13). Shelter

7). Supportive Apartment 14) Homeless/ Undomiciled
Do you live alone or with others?__________________ if so, with whom? ____________________________

Do you have a history of homelessness? _________ If so, please explain: _____________________________ _________________________________________________________________________________________

_________________________________________________________________________________________

Do minor children reside in your home? __________

If so, is there or has there ever been any ACS (Administration for Children’s Services) involvement? ________

Income (circle all that apply & enter monthly amounts)

SSI: $ Family/Family Support: $_____ Veteran's Benefits: $

SSDI: $ SNAP: $___________________ Public Assistance: $

Wages: $ Retirement Benefits: $________ Other:


Total Income: $____________________

Ethnicity (circle all that apply)
African-American American Indian/Native American Caucasian

Asian/Chinese/Japanese/Korean Middle Eastern Pacific Islander

Latino/Hispanic/Cuban/Mexican/Puerto Rican Caribbean/Haitian/Jamaican

Other:__________________________________________________________________________________



Primary Language If other than English,____________________________________________________
Marital Status (circle one) Married Permanent Partner Separated Divorced

Widowed Single, Never Married


Veteran Status Are you a veteran? YES NO
Education Level (circle all that apply)
Less than High School Some High School GED High School Diploma

Trade School Some College Associate's Degree Bachelor's Degree Some Graduate Work Master's Degree Advanced Graduate Degree





School Attended

Years

Major

Did you Graduate?



































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Employment History
Have you ever worked for pay? YES NO

Have you worked in the last 12 months? YES NO

Estimated TOTAL YEARS you have worked for pay:___________________

Estimated TOTAL NUMBER OF JOBS worked for pay:_________________


Please List All Employment. Be sure to include the most recent and longest job:


Dates

Employer

Title/ Type of work

Hourly Wage & Hours per week.
















































Notes:
Medical Alerts (circle all that apply) Chronic Physical Illness Severe Allergic Reactions

Deaf/Hearing Impairment Asthma New Psychiatric Medication Blind/Visual Impairment

Recent Surgery Diabetes Epilepsy/Seizure Disorder Hypertension

Other:____________________________________________________________________________________


Alert Memo: __________________________________________________________________________________________

__________________________________________________________________________________________


Medical & Psychiatric Contacts
Psychiatrist: Agency: Phone:
Address:
How long have you been seeing this psychiatrist?________________________________________________

Email Address:___________________________________________________________________________


______________________________________________________________________________________________________________________________________
Therapist: Agency: Phone:
Address:
How long have you been seeing this therapist?__________________________________________________

Email Address:___________________________________________________________________________


______________________________________________________________________________________________________________________________________
Primary Care MD: Agency: Phone:

Address:

Email Address:___________________________________________________________________________

Emergency Contacts

Primary:_____________________________________________________Phone:________________________

Relationship: ______________________________________________________________________________
Secondary:___________________________________________________Phone:________________________

Relationship: ______________________________________________________________________________


Medical Insurance (indicate applicable insurance and provide the policy number)
Straight Medicaid:___________________ Private Insurance:_______________________________

Medicare:__________________________ Veteran's Benefits:_______________________________

Family pays:________________________ Worker's Compensation: _________________________

Self pay:___________________________ Other:________________________________________

Medicaid Managed Care (please include name of company):_______________________________________

Date of Last Physical Exam:___________________ Date of Last Dental Exam:________________________




Medications (please list all medications with respective dosage & frequency)

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________



Psychiatric Hospitalizations Total # of Hospitalizations:_________
Please list all hospitalizations beginning with the first. Be sure to indicate the most recent.

Indicate name of hospital & dates:


1). 6).

2). 7).

3). 8).

4). 9).


5). 10).
Please indicate precipitants to these hospitalizations: _______________________________________________

____________________________________________________________________________________________________________________________________________________________________________________




Substance Abuse History Please answer all questions.

Alcohol Drugs

Do you have a history of alcohol or drug abuse? YES NO YES NO

If an alcohol or substance abuse history exists, please elaborate: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________



Name of Substance


Date Started

Last Use











































Have you ever been in treatment for an alcohol or drug problem? YES NO

If so, when and where?____________________________________________

Are you currently in treatment or in a support group for alcohol or drug abuse? YES NO

If so, when and where?____________________________________________

Are you interested in being in treatment or a support group for alcohol or drug abuse? YES NO

Legal History Please answer all questions

Have you ever been in jail? YES NO

Have you ever been in prison? YES NO

Have you ever been convicted of a misdemeanor? YES NO

Have you had any arrests for felonies? YES NO

Have you ever physically injured another person? YES NO

Do you have any history of violent behavior? YES NO
If any of the above questions were answered "YES", indicate dates, behaviors, precipitants, legal actions, etc.

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________



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Are you currently involved in any programs, work, school, etc. or is there anything else you would like us to know about you?: _______________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________


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It is very important that all components of this application are absolutely complete. Any missing or incomplete components will, unfortunately, delay the application process. In addition, it is helpful to include all three pieces of information at the same time.


Please allow the Membership Team approximately two weeks to review applications.

Please contact the Membership Office at (718) 742-9884 x 18 with questions.


Thank you for applying to Fountain House Bronx.

Did you remember to include:

1). a current and detailed psychosocial history

2). a current psychiatric assessment

____________________________________________________________________Date:_________________

Prospective Member Signature


____________________________________________________________________Date:_________________

Referral Source Signature

The Clubhouse has control over its acceptance of new members” Standard #2, International Standards for Clubhouse Programs, ICCD.
Revised 9/2014
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.

Name:___________________________________________ Date:_______________________


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

Questions:
1. Have you ever felt that you ought to cut down on your drinking or drug use?
YES NO
2. Have people annoyed you by criticizing your drinking or drug use?
YES NO

3. Have you ever felt bad or guilty about your drinking or drug use?
YES NO
4. Have you ever had a drink or used drugs first thing in the morning to
steady your nerves or to get rid of a hangover?
YES NO

CAGE-AID Questionnaire








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