Get Prime Time Clubhouse

Filling out the Prime Time Clubhouse form online is a straightforward process that guides potential members through the necessary steps for membership. This guide will help you understand each section effectively and ensure that you provide all required information accurately.

Follow the steps to fill out the Prime Time Clubhouse form online:

1. Press the ‘Get Form’ button to obtain the Prime Time Clubhouse form and open it in your preferred editor.
2. In the 'Individual Expressing Interest' section, enter your full name and the date of completing the form.
3. For the 'Statement of Interest', explain why you are interested in participating in the Clubhouse program using your own words.
4. In the 'Additional Information' section, answer questions regarding your authorization to work in the United States and your current activity in the service system. Please indicate whether you have a conservator.
5. Provide information about any benefits you may receive by filling in the approximate monthly amounts for SSI, SSDI, TANF, W/C, VA, Title XIX, SAGA, and other relevant benefits.
6. Fill in the 'Demographic and Diagnoses Update' section with your date of birth, address, phone number, gender, marital status, race, language, religion, living situation, and employment status. Include details regarding your diagnoses and corresponding DSM-5 codes.
7. Complete the 'Primary Clinician/Case Manager' section by providing the name, agency, address, phone number, and email of your primary clinician.
8. For the 'Emergency Contact', fill in the necessary information for a designated emergency contact, including their name, relationship to you, address, and phone number.
9. Use the provided space to share any additional information you wish to communicate.
10. Lastly, sign the form as the potential member and ensure the clinician verifying your diagnosis also signs. Remember to include the date of each signature.
11. If required, attach a Release of Information form to this application before submission.

Get started on completing your Prime Time Clubhouse application online today!