Prospective Member Clubhouse Tour Request Form – Chrysalis

First Name: *

Last Name: *

Email *

What is your date of birth? *

Please provide the best phone number to reach you. *

Guest Name: (optional) - If you would like to bring a guest, please enter their name below.

Guest Email: (optional) - If you would like to bring a guest, please enter their name below.

Please provide the name, agency, email and phone number of the CCS Service Facilitator or Case Manager. *

Please indicate if you receive CCS or CRS Funding. Select "Other" if neither of these apply. *

Clubhouse communities are open to individuals with a history of mental health challenges. Please indicate if you have a mental health diagnosis. *

What support are you looking for from a Chrysalis Clubhouse community? (check all that apply) *