Chelton Loft Clubhouse 104-106 East 126Th Street, 4Th Floor, New York, NY 10035

______

MEMBER APPLICATION FORMS

Chelton Loft Clubhouse 104-106 East 126th Street, 4th Floor, New York, NY 10035

General Inquiries (212) 727-4360

Chelton Loft

A supportive clubhouse for people with histories of mental illness

Dear Applicant:

Thank you for expressing an interest in Chelton Loft, a Clubhouse Rehabilitation program. We ask that all prospective members call to schedule a tour/intake appointment to properly educate themselves regarding the clubhouse model, including our employment and supportive housing services.

In order to expedite your journey at the Loft, there is some information needed as part of the intake process. Please remember that in order to be considered for membership, we need to receive all the paperwork, so it is extremely important that you forward the following items to us (preferably typed) as soon as possible.The following items are required to be submitted; please be sure they are within the mandatory time frames indicated (no exceptions made).

◊ Psychosocial History (within the last six months): completed by a social worker or therapist.

◊ Psychiatric Evaluation (within the last six months): completed by a psychiatrist.

◊ Current Physical Exam (within the last six months): completed by amedical doctor. Must include current PPD or chest x-ray testing for tuberculosis.

◊ HRA Supportive Housing Eligibility & Services Determination Notice (if applicable)

A prospective member is granted immediate access to the clubhouse following the completion of theintake, and then the membership unit will begin to collect allnecessary intake paperwork. While the member will be allowed to begin attending the clubhouse prior to usreceiving all of the paperwork, paperwork should be submitted as soon as possible. New members will also be encouraged to attend a New Member Orientation.

Once all paperwork is collected and active status is granted (first of every month), the individual will then be assigned to a clubhouse program coordinator, acting as a clubhouse liaison on behalf of the member and both internal and external service people/offices.

Please forward all correspondence and/or questions to the Member Services Unit at (212) 727-4364 (phone) or fax documents to (212) 727-4379. Thank you for your interest in our program and we hope to hear from you soon.

Sincerely,

Members and Staff of Chelton Loft

Chelton Loft Referral for Membership

Date of this referral: ______

Referral completed by:______

Personal Information

Name:______Date of Birth: ______

Address (include apt/room #):______

______

Social Security #:______Email:______

Phone Number(s)______

Do you have prior involvement with Chelton Loft? ( ) yes ( ) no

If yes, why did you leave the clubhouse? ______

______

Referral Source: Emergency Contact:

Name:______Name:______

Telephone:______Telephone:______

Organization:______Organization:______

______

Relationship:______Relationship:______

Please List Key Support Persons Below.Please include any psychiatrist, therapist, or case managers not already listed above. If in a shelter or residential program, please list case manager there. Release forms should be completedfor any people the member would like us to be in contact with.

Name:______Name:______

Telephone:______Telephone:______

Organization:______Organization:______

______

Relationship:______Relationship:______

Name:______Name:______

Telephone:______Telephone:______

Organization:______Organization:______

______

Relationship:______Relationship:______

AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA

[ThisformhasbeenapprovedbytheNewYorkStateDepartmentofHealth]

PatientName / DateofBirth / SocialSecurityNumber
PatientAddress

I,ormyauthorizedrepresentative,requestthathealthinformationregardingmycareandtreatmentbereleasedassetforthonthisform: InaccordancewithNewYorkStateLawandthePrivacyRuleoftheHealthInsurancePortabilityandAccountabilityActof1996

(HIPAA), Iunderstandthat:

1.ThisauthorizationmayincludedisclosureofinformationrelatingtoALCOHOLandDRUGABUSE,MENTALHEALTHTREATMENT,exceptpsychotherapynotes,andCONFIDENTIALHIV*RELATEDINFORMATIONonlyifIplacemyinitialsontheappropriatelineinItem9(a).Intheeventthehealthinformationdescribedbelowincludesanyofthesetypesofinformation,andI initialthelineontheboxinItem9(a),Ispecificallyauthorizereleaseofsuchinformationtotheperson(s)indicatedinItem8.

2.IfIamauthorizingthereleaseofHIV-related,alcoholordrugtreatment,ormentalhealthtreatmentinformation,therecipientis

prohibitedfromredisclosingsuchinformationwithoutmyauthorizationunlesspermittedtodosounderfederalorstatelaw.I understandthatIhavetherighttorequestalistofpeoplewhomayreceiveorusemyHIV-relatedinformationwithoutauthorization. If IexperiencediscriminationbecauseofthereleaseordisclosureofHIV-relatedinformation,ImaycontacttheNewYorkStateDivisionofHumanRightsat(212)480-2493ortheNewYorkCityCommissionofHumanRightsat(212)306-7450.Theseagenciesareresponsibleforprotectingmyrights.

3.Ihavetherighttorevokethisauthorizationatanytimebywritingtothehealthcareproviderlistedbelow.IunderstandthatImayrevokethisauthorizationexcepttotheextentthatactionhasalreadybeentakenbasedonthisauthorization.

4.Iunderstandthatsigningthisauthorizationisvoluntary.Mytreatment,payment,enrollmentinahealthplan,oreligibilityforbenefitswillnotbeconditioneduponmyauthorizationofthisdisclosure.

5.Informationdisclosedunderthisauthorizationmightberedisclosedbytherecipient(exceptasnotedaboveinItem2),andthisredisclosuremaynolongerbeprotectedbyfederalorstatelaw.

6.THISAUTHORIZATIONDOESNOTAUTHORIZEYOUTODISCUSSMYHEALTHINFORMATIONORMEDICALCAREWITHANYONEOTHERTHANTHEATTORNEYORGOVERNMENTALAGENCYSPECIFIEDINITEM9(b).

7.Nameandaddressofhealthproviderorentitytoreleasethisinformation:
8.Chelton Loft Clubhouse Suite 4D 104-106 East 126th St NY, NY 10035
8.Nameandaddressofperson(s)orcategoryofpersontowhomthisinformationwillbesent:
9(a). Specificinformationtobereleased:
MedicalRecordfrom(insertdate)to(insertdate)
EntireMedicalRecord,includingpatienthistories,officenotes(exceptpsychotherapynotes),testresults,radiologystudies,films,referrals,consults,billingrecords,insurancerecords,andrecordssenttoyoubyotherhealthcareproviders.
Other:Include:(IndicatebyInitialing)
Alcohol/DrugTreatment
MentalHealthInformation
AuthorizationtoDiscussHealthInformationHIV-RelatedInformation
(b)ByinitialinghereIauthorize
InitialsNameofindividualhealthcareprovider
todiscussmyhealthinformationwithmyattorney,oragovernmentalagency,listedhere:
(Attorney/FirmNameorGovernmentalAgencyName)
10. Reasonforreleaseofinformation:
Atrequestofindividual
Other: / 11. Dateoreventonwhichthisauthorizationwillexpire:
12. Ifnotthepatient,nameofpersonsigningform: / 13. Authoritytosignonbehalfofpatient:

Allitemsonthisformhavebeencompletedandmyquestionsaboutthisformhavebeenanswered.Inaddition,Ihavebeenprovideda

copyoftheform.

Signatureofpatientor representativeauthorizedbylaw.

Date:

* HumanImmunodeficiencyVirusthatcausesAIDS.TheNewYorkStatePublicHealthLawprotectsinformationwhichreasonablycouldidentifysomeoneashavingHIVsymptomsorinfectionandinformationregardingaperson’scontacts.

InstructionsfortheUse

oftheHIPAA-compliantAuthorizationFormtoReleaseHealthInformationNeededforLitigation

ThisformistheproductofacollaborativeprocessbetweentheNewYorkStateOfficeofCourtAdministration,representativesofthemedicalprovidercommunityinNewYork,andthebenchandbar,designedtoproduceastandardofficialformthatcomplieswiththeprivacyrequirementsofthefederalHealthInsurancePortabilityandAccountabilityAct(“HIPAA”)anditsimplementingregulations,tobeusedtoauthorizethereleaseofhealthinformationneededforlitigationinNewYorkStatecourts.Itcan,however,beusedmorebroadlythanthisandbeusedbeforelitigationhasbeencommenced,orwhenevercounselwouldfindituseful.

ThegoalwastoproduceastandardHIPAA-compliantofficialformtoobviatethecurrentdisputeswhichoftentakeplaceastowhetherhealthinformationrequestsmadeinthecourseoflitigationmeettherequirementsoftheHIPAAPrivacyRule.Itshouldbenoted,though,thattheformisoptional.Thisformmaybefilledoutonlineanddownloadedtobesignedbyhand,ordownloadedandfilledoutentirelyonpaper.

WhenfilingoutItem11,whichrequeststhedateoreventwhentheauthorizationwillexpire,thepersonfillingouttheformmaydesignateaneventsuchas“attheconclusionofmycourtcase”orprovideaspecificdateamountoftime,suchas“3yearsfromthisdate”.

Ifapatientseekstoauthorizethereleaseofhisorherentiremedicalrecord,butonlyfromacertaindate,thefirsttwoboxesinsection9(a)shouldbothbechecked,andtherelevantdateinsertedonthefirstlinecontainingthefirstbox.

CHELTON LOFT’S DEMOGRAPHIC INFORMATION

Please complete the information below. This information will assist Chelton Loft and its parent agency Fedcap to gather statistical information that will be helpful to obtain funding and to continue its programs.

Member Name:______Date:______

GENDER:AGE GROUP:

Female( )18-21( )45-64 ( )

Male( )22-44( )65+ ( )

ETHNIC BACKGROUND:RESIDENCE:

African-American( )Manhattan( )

Hispanic( ) Bronx( )

Asian( )Brooklyn( )

Caucasian( )Queens( )

Multi-Racial( )Staten Island( )

Other:______( ) Other( )

LANGUAGE:

Is English your primary language? ( )Yes ( )No

If not, what is your primary language?______

HOUSING

What are your living arrangements?

( )Private; lives alone( )Private; lives with family( )Private; lives with others/non family ( )Supportive housing

( )Homeless; on the streets ( )Homeless; in the shelter( )Other; Specify:______

______

If you are not homeless now, have you ever been homeless in the past? ( )Yes ( )No ( )Not applicable

EMPLOYMENT:

Do you currently work? ( ) Yes( )No

If you do not work, when is the last time that you worked?______

EDUCATION:

What is the highestlevel of education that you have completed?______

FINANCIAL SUPPORT:

SSI( )SSDI( )

Family( )Employment( )

Public Assistance( )

Other: ______

Amount of Monthly Income:______Medicaid #: ______

CRIMINAL HISTORY

Do you have any criminal convictions? ( ) Yes( ) No

If yes please specify______

Are you on probation/parole?( ) Yes( ) No

If yes please specify dates parole/probation will end: Month ______Day ______Year ______

Name:______Date:______

GENERAL INFORMATION

Do you have current health problems?( ) Yes( ) No If yes, please explain:

______

______

______

Do you have any history of substance abuse?( ) Yes( ) No

If yes please indicate length of sobriety:

( ) <3 months( )3-6 months( )6-12 months ( )1 year or more

Do you have any history of sexual abuse?( ) Yes ( ) No

Do you have any history of physical abuse?( ) Yes( ) No

Parenting Skills:

Are you the primary caregiver for any minor child/children in the home?( ) Yes( )No

If yes, how does your disability affect you ability to perform routine childcare? ______

Is there a history of ACS involvement now or in the past? ( ) Yes ( ) No

If yes, please explain.______

What hobbies/social activities do you like or get involved in?

______

______

Which unit (s) are you most interested in volunteering in:

( )Membership/Administrative ( )Café( )Employment/Education ( )Housing ( )Health and Wellness

Goals: What would you like to accomplish at Chelton Loft?

______

______

______

Roadblocks: List any roadblocks you can foresee that might interfere in meeting these goals.

______

______

______

CHELTON LOFT/FEDCAP REHABILITATION SERVICES

STATEMENT OF UNDERSTANDING

To Our Members:

We are pleased to have you participate in our program at Fedcap’s clubhouse, Chelton Loft. Chelton Loft provides a safe and secure place to address your individual issues and to assist you to be prepared and able to complete your program, which may include gaining employment. We will take every precaution to protect your confidentiality and will respect the confidentiality of your relationship with Fedcap as far as possible.

We do not discuss your situation with anyone except for the reasons mentioned below which are in compliance with Federal law or unless you give us written permission to do so:

1.If we learn of any alleged child abuse or neglect or abuse of an elderly person. We are required by law to report this to the State Child Abuse Registry or State Adult Protective Services.

2.If in our judgment a consumer is a danger to himself/herself or others, we may need to break confidentiality to prevent any criminal act.

3.If we are required to present records and/or a counselor to comply with a court order, a subpoena or other legal requirements.

______

Member Name (please print) (Member Signature)

______

(Staff Signature) (Date)

PHOTO AND NAME RELEASE FORM

I, ______, of Chelton Loft hereby

PRINT NAME

• GIVE permission
• DO NOT GIVE permission

to Fedcap to use the photo/s and/or video/film footage taken of me for Fedcap’s use for internal publications and for promotion, outreach, and development of it’s program and services. Such use may include promotional displays, newsletters or bulletins, brochures, annual reports, displays advertising, direct mail fundraising appeals, or Internet use by Fedcap only. Any other use is prohibited unless specific permission is granted by me.

Additionally, do you:

• GIVE permission
• DO NOT GIVE permission

to Fedcap to use your name in any of our publications, such as our monthly newsletter.

If you do give permission for us to use your name, what format would you like it to be in? (for example, full name, first name, first name and last initial, etc):

______

Signed:______Date:______

Note-Chelton Loft publishes a newsletter and the newsletter is published on Fedcap’s website.We will not be held legally responsible for personal issues that may ensue from publications printed on behalf of Chelton Loft, once you have already agreed to the “give permission” heading above.

CHELTON LOFT’S PHYSICAL EXAMINATION FORM

(To be filled out and signed by physician)

Patient Name: ______Gender: □ Female □ Male

Address:______Age: ______Weight:______

Phone #: ______Pulse: ______BP: ______

(Please check any condition that applies to patient)

Condition / Yes / No / N/A / Explanation
Allergy
Skin
Heart
Abdomen
Respiratory
Breast
Genital
Urological
Neurological
Ear, Noise, Throat
Rectal
Diabetic
Musculoskeletal

Laboratory Data Results (if applicable, please check)

Test / Normal / Abnormal / Explain
PPD
EKG
Chest X-Ray
Urinalysis
Hepatitis Profile

PSYCHOTROPIC MEDICATIONS (if applicable)

Medication / Dosage / Frequency

Signature/Stamp:______Printed Name:______Date:______

Chelton Loft’s Member Nutrition and Diet Information Form

(To be filled out and signed by physician)

Member’s Name:______Date:______

Physician’s Name:______

Physician’s Signature:______

1. Does patient have any of the following medical conditions? Please check “yes” or “no”.

Medical Condition / Yes / No
High blood pressure
High cholesterol
Diabetes/Pre-diabetes
Obesity

2. Does patient have any allergies to the following foods?

Foods: / Yes / No
Dairy/lactose
Eggs
Wheat/Gluten
Nuts
Shellfish
Pork
Other (please list)

3. Has patient been prescribed any of the following diets?

Type of Diet / Yes / No
Low salt
Low sugar
Low calorie
Low fat
Gluten free

1. Does patient take MAO inhibiters ( a type of antidepressant?)

Yes _____ No ____

Chelton Loft is a voluntary clubhouse program for adults with a history of mental illness. It is part of Fedcap, a nonprofit organization that has been a leader in developing training and employment programs for people with disabilities and other significant barriers to employment since 1935.

Fedcap helps America work. Fedcap’s mission is to empower people with barriers to move towards economic independence as valued members of the workforce. From the visually impaired to returning veterans to youth transitioning out of foster care, Fedcap enables individuals to support themselves, be part of a community, and enjoy the sense of accomplishment that comes from work. Through training, job placement, and socially responsible outsourcingtm services to business and government, Fedcap has helped thousands of people transform their lives and successfully enter the workforce. To learn more about Fedcap, or to make a donation, please visit or call (212) 727-4200.

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