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About
Clubhouses
- Compass
- Lotus
Catering
Partner with Us
Connect
Donate

Address

82 Brigham Street
Marlborough, MA 01752

Need an Appointment?

508.485.5040

Name *

DOB

Date / Time

Address

City

Zip Code

Home phone

Mobile phone

Email *

Gender *

Male
Female
Non-binary
Prefer not to say
Self describe

Preferred Pronouns

Race

Ethnicity

Psychiatric Diagnosis

Special Referral would

Employment Status

Unemployed
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Seeking
Interested
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Other

Education Status

Pursuing Hi-Set
Associates
Bachelor
Certificate
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Other

Communication Preferences

Phone
Mail
Text
email
Social Media

Referral Agency – Referral Type

Self, Family Friends
Public Shelter for the Homeless
Private, Practitioner (Psychiatrist/MD)
Homeless Outreach Team
Community Mental Health Center/Clinic
Police, Courts, Forensic Hospital
Another Clubhouse
Other

Referral Agency Name

City

Referral Contact

Phone

Primary 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)

Needs Transportation

Yes
No

Our Clubhouse can provide/request transportation to:

Ashland
Framingham
Hopkinton
Hudson
Marlborough 
Natick
Northborough
Southborough
Westborough

Date / Time

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82 Brigham St, Marlborough, MA 01752
508-485-5051
Fax: 508-485-8807
attn: ENROLLMENT
Email: lotusnewmember@novustogether.org

Together, Change Happens.

82 Brigham Street Marlborough, MA 01752

novus@novustogether.org

508.485.5040

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Lotus Member Application Form

Together, Change Happens.

508.485.5040

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