Referral Form

**Ensure the form is fully completed for consideration.**

Membership Criteria

Applicants for membership at Threshold must meet the following criteria:

• Have a desire to be an active participant in a supportive and vital community

• Have a Severe and Persistent Mental illness (Bipolar Disorder I, Schizophrenia, Schizoaffective Disorder, Major Depression, or Psychosis NOS) which is the primary focus of treatment.

• Be at least 18 years of age.

• Must have Medicaid from the Alliance Health’s catchment area, qualify for IPRS funding, or arrange a Fee for Service contract.

To Apply for Membership

To apply for membership, please complete and submit the following documents:

• A completed Referral Form

• A current Diagnostic Assessment or a Comprehensive Clinical Assessment or documentation supporting mental health diagnosis with PSR as a recommended service

• Person Centered Plan, with goal for PSR (only if you have CST)

Submit documents to Erica Weaver, Senior UM/Intake Coordinator, at e.weaver@thresholdclubhouse.org or fax to (919) 956-7703 (call (919) 682-4124 before faxing).

For questions about application materials or process, or to request an application by mail, contact Erica at the contact information above.

For Clubhouse services outside Alliance Health’s catchment area, visit Clubhouse International.