Drop-In Center Welcome Form

Our mission is to empower adults experiencing mental illness to achieve their full potential by providing recovery-oriented programs and services in a safe and accepting environment. Our Space provides person-centered, strength-based, recovery-oriented services to adults living with severe and persistent mental illness and/or substance abuse issues. Our services provide hope and promote personal growth and healing through one-on-one and peer-facilitated groups, occupational therapy, wellness, and skill-building activities. All programs are in response to the expressed needs of the individual and we encourage autonomy among the members we serve.

What will I gain from Our Space?

• Create and maintain a network of peers while interacting with others who have shared similar experiences

• Realize your hopes and dreams

• Learn skills through participation in educational groups

• Receive support through participation in recovery groups

• Enjoy enriching experiences through community outings and integration

• Gain leadership skills through member management opportunities and or prevocational work

• Be empowered

Basic Participant Information

Preferred Name or Nickname

Date of Birth

Month

Day

Year

Emergency Contact Name and phone number

Preferred Method of Communication

Purpose of Visit / Needs Today

Demographic Information

CCS Enrollment

Yes

Housing Status

Housed

Unhoused

Participant Rights & Expectations

I agree to respect myself and others.

I understand substance use is not allowed on premises.

I understand participation is voluntary.

I will respect the privacy of others.

Photo / Media Consent

I give permission for non-identifying photos.

I do NOT want to be included in any photos.

Consent & Confidentiality

I understand that the Drop-In Center is voluntary and peer-support based.

I understand that my information is confidential unless there is a safety concern.

Electronic Signature

By typing your full name below, you are providing your electronic signature and authorizing this submission in place of a physical signature.

Type your full name here as your electronic signature.