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Pioneer Clubhouse Referral Form

Pioneer Clubhouse Referral Form

About Pioneer Clubhouse

Pioneer Clubhouse is a safe, respectful community of people with lived experience of mental illness.

Pioneer Clubhouse is a place to come, a place to return, a place of meaningful work and a place for meaningful relationships.

Membership is open to adults with a history of mental illness.

Membership is free and for life.

Each member is valued, needed and wanted.

Initial Tour
Preferred Day(s)
Personal Details
How did you find out about Pioneer Clubhouse?
Please select
Primary Diagnosis

*To be a member you must have a primary diagnosis of mental illness.

Please select one
Do you have any other diagnoses?
Tick as many as apply
Are you happy for us to keep in contact with you until you become a member?
Please select* - required
 

Mandatory field(s) marked with *