Member Application (Staten Island) Applicant InformationFirst Name(Required) Middle Initial Last Name(Required) Date of Birth(Required) MM slash DD slash YYYY Current Gender(Required) Female Male Non-binary Prefer to self describe Do not wish to answer Please select the gender you currently identify with. *Prefer to self describe Last four digits of Social Security Number (Optional)Please enter a number from 1000 to 9999.Please give the last four digits of social security numberAddress(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone(Required)Alternate PhoneEmail Enter Email Confirm Email Do you live in a housing program?(Required) Yes No Name of Housing Program: If you live in a housing program, what agency operates the progam?Who is recommending you?Name Agency Name Staff Name Type of Agency Agency Email How long has this person known you? Years Months Have you toured Venture House?(Required) Yes No Date of Tour MM slash DD slash YYYY What is your main goal in joining Venture House?(Required)CommunityEducationEmploymentBenefits/ResourcesSocialization/FriendsWellnessOtherWhy would Venture House be a good place for you?(Required)What challenges or barriers are keeping you from achieving your goals?(Required)Housing InformationCurrent Housing Type (choose one)(Required) Own Home/ Apartment (Non-subsidized) Home of Family Member Supportive Apartment Supported Apt. (Subsidized) SRO 24 Hr. Supervised Housing Nursing Home Shelter Homeless/ Undomiciled How long have you been Homeless / Undomiciled? Years Months Do you live alone?(Required)YesNoWith whom do you live? Do you have a history of homelessness?(Required)YesNoPlease explain:Do minor children live in your home?(Required)YesNo*Is there or has there ever been any ACS (Administration for Children’s Services) involvement?(Required) No Yes Demographic InformationPlease select your source(s) of income(Required) SSI SSDI Wages Family/Family Support SNAP Retirement Benefits Veteran's Benefits Public Assistance Other Please indicate your total monthly income(Required)Please enter a number from 0 to 10000000.Please indicate your ethnicity(Required) Black (African American) Black (Afro-Caribbean) Black (African Continent) Black (other) Hispanic or Latino (Cuban) Hispanic or Latino (Mexican) Hispanic or Latino (Puerto Rican) Hispanic or Latino (Dominican) Hispanic or Latino (Central American) Hispanic or Latino (South American) Pacific Islander / Native Hawaiian Native American / American Indian Asian (Far East) Asian (South East) Asian (Indian Subcontinent) White (European) White (Middle Eastern) Other Do not wish to answer Select all that applyPrimary Language(Required) English Spanish Chinese (including Mandarin and Cantonese) American Sign Language (ASL) Other Please select the language you communicate best with.Please indicate language: Marital Status(Required) Single/Never Married Married Permanent Partner Separated Divorced Widowed Do not wish to answer Do you have children?(Required) Yes No How many?Please enter a number from 1 to 100.Are you a Veteran?(Required) Yes No Do not wish to answer Are you a US Citizen/Permanent Resident?(Required) Yes No Do not wish to answer Education History(Required) None Some High School High School Diploma High School Equivalency or GED Trade School Some College Associate's Degree Bachelor's Degree Some Graduate Work Master's Degree Advanced Graduate Degree Please indicate your highest level of educationAre you currently Employed?(Required) Yes No Have you ever worked for pay?(Required) Yes No Have you worked in the last 12 months?(Required) Yes No Please list the number of years you've had paid work:Medical and PsychiatricMedical Alerts (select all that apply)(Required) None Chronic Physical Illness Asthma Severe Allergic Reactions New Psychiatric Medication Blind / Visual Impairment Deaf / Hearing Impairment Recent Surgery Diabetes Epilepsy / Seizure Disorder Hypertension Other select all that applyPlease indicate "other" medical alert(Required) Alert Memo:Medical & Psychiatric ContactsContact 1(Required) Name Agency Type(Required)PsychiatristTherapistPrimary Care PhysicianPhone(Required)Email Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country How long have you been seeing this professional? Years Months Contact 2(Required) Name Agency Type(Required)PsychiatristTherapistPrimary Care PhysicianPhone(Required)Email Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country How long have you been seeing this professional? Years Months Contact 3 Name Agency TypePsychiatristTherapistPrimary Care PhysicianPhoneEmail Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country How long have you been seeing this professional? Years Months Emergency ContactsPrimary(Required) Name Relationship Phone(Required)Email Primary Name Relationship PhoneEmail Medical InsurancePlease indicate applicable insurance and provide policy number(Required) Straight Medicaid Private Insurance Medicare Veteran's Benefits Worker's Compensation Self Pay Other Select all that applyPlease indicate insurance:(Required) Policy Number: Medicaid Managed Care?(Required) Yes No Unkown Please give name of company: Health and Recovery Plan (HARP)(Required) Yes No Unkown Home and Community Based Services (HCBS)?(Required) Yes No Unkown Date of Last Physical Exam Month Day Year Date of Last Dental Exam Month Day Year PsychiatricMost recent Psychiatric diagnosis (DSM V)(Required) Schizophrenia Schizoaffective Disorder Major Depressive Disorder Bipolar Other Please select all that applyPlease indicate "other" psychiatric diagnosis:(Required) Secondary Diagnosis Tertiary Diagnosis Total Number of Psychiatric Inpatient Hospitalizations:(Required)Please enter a number from 0 to 1000.Please list your first and most recent hospitalization, indicating name of hospital and dates(Required)Hospital NameDates (approximate) Add RemoveSubstance Use History (Your answers will not influence your application decision)Do you currently smoke tobacco or use tobacco products?(Required) Yes No Do you have a history of smoking or using tobacco products?(Required) Yes No Do you have a history of alcohol or drug abuse? (Select all that apply)(Required) Alcohol Drugs Neither Do not wish to answer Please select all that applyHave you ever been in treatment for an alcohol or drug program? Yes No When and where? Are you currently in a treatment or a support group for alcohol or drug use? Yes No Which group(s)? Are you interested in being in treatment or a support group for alcohol or drug use? Yes No Legal HistoryHave you ever been in jail? Yes No Have you ever been in prison? Yes No Have you ever been convicted of a misdemeanor? Yes No Have you ever been convicted of a felony? Yes No Have you ever physically injured another person? Yes No Do you have any history of violent behavior? Yes No Please indicate dates, behaviors, legal actions, etc:(Required)DocumentationHow would you like to submit your supporting documentation?(Required) Fax Mail Online Email Psychiatric Assessment(Required)Max. file size: 256 MB.Psychosocial History(Required)Max. file size: 256 MB.General Basic Medical FormMax. file size: 256 MB.Please fax documentation to (718)727-2989 in order to be considered for membership(Required) I understand Please mail documentation to 1442 Castleton Ave, Staten Island, NY 10302 in order to be considered for membership(Required) I understand Please email documentation to intake@venturehouse.org in order to be considered for membership(Required) I understand Consent(Required) I authorize the release of my health information to Venture House for an application for Clubhouse membership.I authorize the release of my health information to Venture House for an application for Clubhouse membership. I understand that I have the right to revoke this authorization at any time through written notice and thus cease any and all information sharing between Venture House and other providers/parties.Signature (please type full name)(Required)