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
The Membership Team
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
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:
be interested in attending Fountain House Bronx, as membership is voluntary.
have a primary presenting problem associated with severe and persistent mental illness.
______________________________________________________________________________________________________________________________________ Therapist: Agency: Phone:
How long have you been seeing this therapist?__________________________________________________
Substance Abuse History Please answer all questions.
Do you have a history of alcohol or drug abuse? YES NO YES NO
If an alcohol or substance abuse history exists, please elaborate: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Are you currently involved in any programs, work, school, etc. or is there anything else you would like us to know about you?: _______________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________
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.
“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.
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?
2. Have people annoyed you by criticizing your drinking or drug use?
3. Have you ever felt bad or guilty about your drinking or drug use?
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?