Referral Form

**Please make sure to fill out the form in its entirety for the individual to be considered.**

To Apply for Membership

To apply for membership, please complete and submit the following documents to the Senior Utilization Management- Intake Coordinator, Erica Weaver, at e.weaver@thresholdclubhouse.org. You can also fax the documents to her attention (919) 956-7703. Please call Erica at (919) 682-4124 before faxing referral.

  • A completed Referral Form (click “Referral Form” to apply)

  • A current Diagnostic Assessment or a Comprehensive Clinical Assessment with PSR as a recommended service

If you have specific questions about the application materials or process, or need an application mailed to you, please contact Erica Weaver, Threshold Membership Coordinator at (919) 682-4124 or e.weaver@thresholdclubhouse.org

If you are looking for Clubhouse services outside of Alliance Health’s catchment area please visit the Clubhouse International website at http://www.clubhouse-intl.org