Please enable JavaScript in your browser to complete this form.Name *DOBDate / Time that 1) Employment AddressCityZip CodeHome phoneMobile phoneEmail *Gender *MaleFemaleNon-binaryPrefer not to saySelf describePreferred PronounsRaceEthnicityPsychiatric DiagnosisEmployment StatusUnemployedEmployedSeekingInterestedPrefer not to sayOtherEducation StatusPursuing Hi-SetAssociatesBachelorCertificatePrefer not to sayOtherCommunication PreferencesPhoneMailTextemailSocial MediaReferral Agency – Referral Type Self, Family FriendsPublic Shelter for the HomelessPrivate, Practitioner (Psychiatrist/MD)Homeless Outreach TeamCommunity Mental Health Center/ClinicPolice, Courts, Forensic HospitalAnother ClubhouseOtherReferral Agency NameCityReferral ContactPhonePrimary Reasons to attend Clubhouse (i.e. employment, education, socialization, family services) 1)2) 3)Special Medical Conditions and Allergies (Please note anything that would be helpful) Special Medical Conditions and Allergies (Please note anything that would be helpful)Needs TransportationYesNoOur Clubhouse can provide/request transportation to: Ashby Ayer Berlin Bolton Fitchburg Groton Harvard Lancaster Leominster Lunenburg Pepperell Shirley Sterling TownsendDate / TimeSubmit 356 Broad St, Fitchburg, MA 01420978-696-5171Fax: 978-696-3386attn: ENROLLMENTEmail: compassnewmember@novustogether.org