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Crossroads Clubhouse
1888 East 15th Street Tulsa, OK 74104 Ph: 918.749.2141 Fax: 918.749.2150
CROSSROADS ENROLLMENT APPLICATION (Please carefully read and print all answers. All blank spaces must be filled.)
Personal Information
Today’s Date:______________________
Name: First: ___________________________M.I.: _______Last:______________________________________
Preferred Name: ________________________________Maiden Name: _________________________________
Date of Birth: ____/____/____ SSN #: _____-_____-_____
1. Referral Type
□ Self, Family, Friends □ Private Practitioner (Psychiatrist/MD) □ Community Mental Health Center
□ County/Local Hospital □ Another Clubhouse □ State Social Services □ County Social Services
□ Vocational Rehab □ Shelter for the Homeless □ Mental Health Court □ Other: _________________________
2. Referring Agency:_________________________
Applicant’s Mailing Address:___________________________________________________________________
City: ______________________________State:___________________Zip: _____________________________
Permanent Address:___________________________________________________________________________
City:__________________________________State:_______________Zip:______________________________
Phone: ( ) _________________________ Alternative Phone: ( )______________________________
1. Housing Type
□ Own Home/Apartment (Non-subsidized) □ Home of a family member (shared responsibility) □ Home of a family member (dependent on family □ Temporary Housing □ Supported apartment □ Supervised housing
□ Group home □ Psychiatric Hospital □ Nursing Home □ Prison/Jail □ Homeless □ Home of a friend
□ Other (please specify):________________________________________
2. Housing Status
□ Alone □ With Roommate(s)/ Housemate(s) □ With Parent(s) □ With Other Adult Relative(s) □ With minor child(ren) □With Partner □ With Partner and Child(ren) □ Institutional setting
3. Housing Satisfaction
□ Very Satisfied □ Somewhat Satisfied □ Neutral □ Somewhat Unsatisfied □ Very Unsatisfied
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Crossroads Clubhouse
1888 East 15th Street Tulsa, OK 74104 Ph: 918.749.2141 Fax: 918.749.2150 4. Social Interaction:
Do you have a close friend you can talk to? ○Yes ○No
Do you have frequent conflicts with friends (more than once per month)? ○Yes ○No
Are you satisfied with your family relationships? ○Yes ○No
Do you have conflicts with your family members (more than once per month)? ○Yes ○No
Do you feel isolated? ○Yes ○No
1. Gender:
□ Male □ Female □ Other (please specify)__________________________________
2. Ethnicity:
□ African American □ American Indian/Native American □ Asian □ Caribbean □ Caucasian
□ Latino/Hispanic □ Middle Eastern □ Pacific Islander 3. Language:
□ English □ Primary Other (please specify)____________________________________
4. Marital Status
□ Single, Never Married □ Widowed □ Permanent Partner □ Divorced □ Separated □ Married 5. Number of Minor Children:____________
6. Primary Weekday Activity
□ Independent Employment □ Clubhouse Work □ Parenting/Care Taking at Home □ Other Volunteer Work
□ School-High School □ Day Program Outside of the Clubhouse □ School-Trade School/College
□ In Hospital/House Bound Psychiatric Reasons □ Transitional Employment □ No Structured Daytime Activity
□ Enclave Work Sheltered Workshop
7. Primary Reasons for wanting to attend Crossroads? ________________________________________
8. Education Level:
□ Less than High School □ GED □ High School Diploma □ Trade School/Vo Tech □ Some College
□Associate’s Degree □ Bachelor’s Degree □ Some Graduate Work □ Master’s Degree □ Advanced Graduate 9. Do you have outstanding student loans?________________________________________________
10. Are you interested in continuing your formal education?_________________________________
1. Current Employment
□ Full Time (32 hours per week or more)
□ Part Time (Less than 32 hours per week
□ Day Labor (Selected to work each day at employment agency)
□ Contract Labor (Selected to work on jobs or projects for a limited period of time)
□ No job at this time and I am not looking.
□ No job at this time and I am looking for employment
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Crossroads Clubhouse
1888 East 15th Street Tulsa, OK 74104 Ph: 918.749.2141 Fax: 918.749.2150 2. Job held the longest:___________________________________________
3. Income Source(s) – Type of Income
○ Wages-Independent Employment ○ Local Assistance (County/State)
○ Wages-Transitional Employment ○ AFDC
○ Wages-Supported Employment ○ Veteran’s Benefits
○ Wages-Shelter Workshop ○ Retirement Benefits
○ SSDI ○ Family Support
○ SSI ○ Friend Support
○ General Assistance (State) ○ No Financial Support
○ Other (please specify):__________________________________________
4. Total Amount of Monthly Income:________________________________
5. What type of work would you like to do?__________________________________
1. Medical Alerts- Check all that apply.
□ Chronic Physical Illness □ Severe Allergic Reactions
□ Deaf/Hearing Impairment □ New Psychiatric Medication
□ Blind/Vision Impairment □ Recent Surgery
□ Epilepsy/Seizure □ Diabetes
□ Asthma □ Hypertension
□ Other Physical Disability: (please specify)____________________________________
1. Emergency Contact Information:
Name:_______________________________
Relationship to Applicant:________________________________
Telephone:_______________________________________
2. Treatment Provider:
Name:_______________________________________________
Agency:______________________________________________
Address:______________________________________________
Telephone:____________________________________________
Release? (Y/N):________________________________________
1. Has applicant ever been convicted of a misdemeanor?
○Yes ○ No
2. Has applicant ever been convicted of a felony?
○Yes ○ No
3. Please, explain:__________________________________________________________________________________
_____________________________________________________________________________________________
4. Does (s)he have a history of violent behavior toward others?
○Yes ○ No
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Crossroads Clubhouse
1888 East 15th Street Tulsa, OK 74104 Ph: 918.749.2141 Fax: 918.749.2150 1. Medical Insurance Policy(s): Check all that apply.
Policy Type
○ Medicaid ○ Veteran’s Benefits
○ Medicare ○ Worker’s Compensation
○ Medicare, Managed Care ○ Family Pay
○ Private Insurance ○ Self-pay (no insurance)
○ Other (please specify):________________________________________
2. Last Medical Exam:
MM/DD/YYYY:___________________
3. Last Dental Exam:
MM/DD/YYYY:___________________
4. Nutrition:
Number of meals per day:_____________________________
Special dietary needs:_________________________________
5. Exercise:
○ 30 mins per day ○ 30 mins weekly ○ 30 minutes three times per week ○ I do not exercise
6. Are you currently taking prescribed medications or over the counter medications, natural remedies or vitamins and minerals?
○ Yes ○ No
7. If you are female, are you currently pregnant?
○ Yes ○ No
8. Are you taking your medications as prescribed?
○ Yes ○ No
Other (please specify):________________________________________________
9. Psychiatric History
Total Number of Hospital Admissions:_____________________________________
Estimate Total Months of ALL Hospitalizations:__________________________________
Length (months) of LONGEST Hospitalization:_______________________________________
To the best of my knowledge the above information is accurate.
Signature of Applicant:_______________________________________________________________________
Date:______________________________________________________________________________________
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Crossroads Clubhouse
1888 East 15th Street Tulsa, OK 74104 Ph: 918.749.2141 Fax: 918.749.2150
Pages 5 and 6 must be filled out by a treatment provider.
Name of Applicant (please print):________________________________________________________
Applicant’s Date of Birth:_________________________________________
1. Primary Diagnosis
○ Schizophrenia ○ Major Depression
○ Schizoaffective Disorder ○ Other Psychotic Disorder
○ Bi-Polar Disorder ○ Other Major Mental Illness
If other was selected, please specify:_________________________________________________
2. DSM IV Axis I
Written Diagnosis:____________________________________________
Diagnostic Code:______________________________________________
3. DSM IV Axis II
Written Diagnosis:____________________________________________
Diagnostic Code:______________________________________________
4. DSM IV Axis III
Written Diagnosis:____________________________________________
Diagnostic Code:______________________________________________
5. DSM IV Axis IV
Written Diagnosis:____________________________________________
Diagnostic Code:______________________________________________
6. DSM IV Axis V
Written Diagnosis:____________________________________________
Diagnostic Code:______________________________________________
7. History with Alcohol Yes No Has applicant had a problem with alcohol? ○ ○
Has applicant been in treatment for an alcohol problem? ○ ○ Is applicant currently in treatment or in a support group? ○ ○ Does (s)he want help with an alcohol problem? ○ ○ How long has (s)he been clean and sober?:_________________________________
8. History with Drugs Yes No Has applicant had a problem with drugs? ○ ○
Has applicant been in treatment for a drug problem? ○ ○
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Crossroads Clubhouse
1888 East 15th Street Tulsa, OK 74104 Ph: 918.749.2141 Fax: 918.749.2150
