RM_StatsUser InformationBasic DetailsMental Health InformationDemographic InformationEducation, Employment,SkillsGrand Avenue Club (GAC) is based on “the Clubhouse Model of Psychosocial Rehabilitation” which is an evidence-based practice as defined by the United States Substance Abuse and Mental Health Services Administration (SAMHSA). It is desirable for potential members to have a monthly income, shelter, food, and appropriate medical/psychiatric care, as we do not have the resources to work on these areas at the outset of membership. GAC is unable to accept individuals whose primary diagnosis is dementia, traumatic brain injury, or developmental disability, including Autism Spectrum Disorders. GAC is avidly interested in recruiting members who are able to work side-by-side with other members and staff to run GAC. We are also interested in employment and/or educational goals individuals may have. This form is for potential members that have the following information (preferably their own): Cellphone Number Email Address All potential members must live in Milwaukee County. Please reply honestly to the questions that follow. Your responses will help our Membership Team get to know you. All information is kept confidential and helps with applying for grants. If you have any questions or concerns please call our Membership Team at 414-727-3366 or email at membership@grandavenueclub.org This application will take about 15 minutes to complete. After finishing, you will be provided with additional instructions. First Name *Last Name *Email *Cell Phone NumberDo you consent to having text messages sent to this phone number? If this is not a cell phone, select No. * Yes No Is someone assisting you with filling out this application? * Yes No Please enter their name and their relationship to you. *Gender * Male Female Transgender Nonbinary Two-Spirit Other Prefer not to say Date of Birth *Race/Ethnicity *African AmericanCaucasianAsianNative AmericanHispanic/LatinoNon-white HispanicBiracial/MultiracialOtherPlease enter the address where you would like to receive postcards and other mailings in regards to your membership application process and other member only postcards. Mailing Address Address Line 1 * Address Line 2 City * State or Region AL AK AZ AR AA AE AP CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY State or Region * Country Zip Are you currently working with a case worker? * Yes No Are you currently working with a therapist? * Yes No Are you currently working with a psychiatrist? * Yes No Please list their names and agencies, as well as how long you have been working with them. *What is your primary diagnosis? * Depression Bipolar Disorder Schizophrenia PTSD Personality Disorder Anxiety Alcohol/ Substance Abuse Traumatic Brain Injury/ Dementia Developmental/ Cognitive Disability Autism Spectrum Disorder/ Asperger's Syndrome OtherWe will verify your diagnosis with your provider after the application has been submitted. Have you ever been hospitalized for mental or emotional symptoms? * Yes No Were you hospitalized for those reasons in the last 3 years? * Yes No Who referred you to GAC?How did you hear about Grand Avenue Club?What is your current living situation? * Rent Own Treatment Center Shelter Homeless Group Home (Community-Based Residential Facility) Family Member OtherWhat is the address of the shelter you are at? Address Line 1 Address Line 2 City State or Region Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas, The Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, The Democratic Republic Of The Cook Islands Costa Rica Cote D'ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia, The Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and the McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iraq Iran Ireland Isle Of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, Republic Of Kosovo Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia, The Former Yugoslav Republic Of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States Of Moldova, Republic Of Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territories Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and The Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania, United Republic Of Thailand Timor-leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Country Zip How will you be coming to GAC? * Public Transportation Self (i.e. Drive, Walk) Paratransit Friend/Family Member OtherWhat are your sources of financial support? (Check all that apply). * Paid Employment Family SSI SSDI Unemployment IDAP Child Support W2 None OtherWhat is your monthly income? * No Income Less than $1000 per month $1000-$1500 per month $1500-$2000 per month $2000-$2500 per month More than $2500 Highest level of education completed Some High School High School Diploma GED/HSED Some College Associates Degree Bachelor's Degree Master's Degree Doctorate Professional Degree Are you currently enrolled in school? Yes No Are you interested in returning to school? Yes No Current Employment Status * Part-time employment Full-time employment Unemployed Retired Stay-at-home parent (or caretaker) Student Disabled OtherEmployment History * Never Employed Intermittent Employment (Major gaps in employment) Stable Employment (Minimal gaps in employment) What is your current Legal History? * Never Convicted Currently on Probation Currently on Parole Currently on Deferred Prosecution Convicted of a Felony Convicted of a Misdemeanor Have you ever been convicted of a sexual offense? * Yes No Do you have a history of alcohol and/or drug misuse? * Alcohol Drugs (prescription or illegal) Both None Grand Avenue Club offers opportunities to discover and use your strengths, talents, and abilities. All work at GAC is intended to assist you in enhancing your self-worth, purpose, and self-confidence. Please rate the following from 1 to 5 stars with 1 being not important to me at this time to 5 being the most important to me at this time. Paid Employment * Education/ Vocational program in the community * Socializing * Computer skill development * I have experience and enjoy: * Answering Phones Cashiering Working with people/Customer Service Preparing meals Filing Data entry Meal planning Journalism/Writing Public speaking Book keeping/Accounting OtherI would like to learn more about * Data entry Cashiering Working with people/Customer Service Preparing meals Book keeping/Accounting Filing Meal planning Public speaking Journalism/Writing Answering phones OtherWhy are you interested in becoming a GAC member? *Is there anything else you would like us to know about you? Note: It looks like JavaScript is disabled in your browser. Some elements of this form may require JavaScript to work properly. If you have trouble submitting the form, try enabling JavaScript momentarily and resubmit. JavaScript settings are usually found in Browser Settings or Browser Developer menu.
