MEMBERSHIP APPLICATION Membership Application for Joining 9musesartcenter "*" indicates required fields 9MUSES is a Membership Application program, requiring each member to complete & submit the following form prior to receiving services.Date* MM slash DD slash YYYY Name* First Last Address* Street Address Apartment Number City State: Zip: Email* Phone*Emergency Contact* First Last Relationship* Phone*DemographicsDate of Birth* MM slash DD slash YYYY Race or Ethnicity:*WhiteBlack or African-AmericanAmerican Indian or Alaskan NativeAsianNative Hawaiian or Other Pacific IslanderFrom Multiple RacesOthersGender:* Female Male Other Pronoun:*He/HimShe/HerThey/TheirOthersOur Product refers to users using the pronouns that you select below.Marital Status:*MarriedWidowedDivorcedSeparatedNever MarriedIncome:*$0 – $18,000$18,000 & AboveEducation:*Less Than High School DegreeHigh School Degree or Equivalent (e.g., GED)Some College But No DegreeAssociate DegreeBachelor DegreeGraduate DegreeEmployment:*Employed, working 1-39 hours per weekEmployed, working 40 or more hours per weekNot employed, looking for workNot employed, NOT looking for workRetiredDisabled, not able to workCitizenship: USA* Yes No Who do you currently live with?*SpouseChildrenParentsFriendsAloneFamily BenefitsInsurance Information*MedicaidMedicareVeteransOtherNoneI Have received Mental Health services within the last 5 years:* Yes No I am currently receiving behavioral health services at:*Community Mental HealthSubstance TreatmentPrivate FacilityNone(if no, annual membership fees apply)My treatment providers name: PhoneMy transportation provider name: PhoneMy case manager’s name: PhoneI have received behavioral health services:* in the past 12 months within the past 5 years Are you registered to VOTE in the State of Florida?* Yes No MHA'S CLIENT PROTOCOLS RECEIVED* By checking this box I affirm I have received and understood MHA's Client Protocols. CLICK HERE TO RECEIVE A COPY OF THE "MHA'S CLIENT PROTOCOLS" HAVE YOU RECEIVED THE 9MUSES MEMBERSHIP AGREEMENT THE 9MUSES MEMBERSHIP AGREEMENT* By checking this box I affirm I have received and understood The 9MUSES Membership Agreement. I HAVE SIGNED THE MEMBERS CONSENT/RELEASE FORM MEMBERS CONSENT/RELEASE FORM* By checking this box I affirm I have received and understood Members Consent/Release Form. By signing below, I authorize Mental Health America to release information regarding my participation for purposes of program development,data gathering and fund contract compliance. Consent* By signing below, I authorize Mental Health America to release information regarding my participation for purposes of program development,data gathering and fund contract compliance. MY INITIALS:* My signature affirms that this information provided by me is complete and accurate.Consent My signature affirms that this information provided by me is complete and accurate. MY SIGNATURE: Consent I understand that my participation is voluntary and for the purpose of personal growth. I understand that it is not a treatment program and that it is my responsibility to select activities in which I can safely participate. MY SIGNATURE: Upload valid state IDMax. file size: 100 MB.CommentsThis field is for validation purposes and should be left unchanged.
