Community 43 Application
Membership Application (13 minutes to apply)
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Have you heard back from any of our staff regarding this application question? If you have any questions please call  (602)274-7373 or email info@community43.org
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First Name *
Middle Name
Last Name *
Do you have a legal guardian? *
If yes, when is the guardian's name and phone number?
Do you have a history or alcohol or drug abuse? Your answers will not influence your application decision.
If YES, in the past 12 months?
Have you ever been in treatment for an alcohol or drug problem?
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Are you currently in treatment for an alcohol or drug problem?
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Are you interested in receiving treatment or support for an alcohol or drug problem?
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Psychiatric Diagnosis (DSM V): *
Required
Date of birth *
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Age *
Gender identity *
Required
If you are not known by your legal name, please enter your preferred name below:
Sexual Orientation
Address *
Primary Phone number *
Email Address *
How did you hear about Community 43? *
Have you ever been convicted of a sex offense or required to register as a sex offender?  If yes, unfortunately Community 43 is unable to accommodate prospective  members who have been convicted of a sex offense or must register as a sex offender at this time. *
Have you signed a release of information for communication between your agency/provider and Community 43 (A signed release of information is needed to proceed)
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Referring staff name *
Referring agency / Type of Agency *
Agency Phone number
Agency Address
Agency/staff email
Check if you've had a tour of Community 43?
When was the tour?
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Community 43 is an agency that offers voluntary support and other services.Do you voluntarily want the support and other services offered at Community 43?
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What interests you to join Community 43? *
Required
Why would Community 43 be a good place for you? *
Are any challenges or barriers keeping you from achieving your goals? *
Medical Insurance *
Required
Approx. date of last physical exam?
Approx. date of last dental exam?
Do you live alone?
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If NO, with whom do you live?
Do you have any allergies?
 *
If yes, please list them.
 *
Are you currently taking any outside medications?
 *
If yes, please list them along with their dosages.
 *
Housing Type
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Do you have a history of homelessness?
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If YES, please explain
Do any minor children live in your home? *
Income *
Required
For the income above, please enter the monthly amounts received from each source (ie. SSI: $700, family benefits $200) *
Ethnicity (please check all that apply) *
Required
Primary Language: If other than English:
Do you need an interpreter?
Veteran Status: Are you a veteran? *
Citizenship: Are you a US Citizen/Permanent Resident? *
Marital Status: *
Required
Legal History: Please answer all questions (Please note: A "yes" response doesn't automatically mean your application will not be reviewed)
If any of the above questions were answered "yes," please indicate dates, behaviors, precipitants, legal action, etc.
Education (check all that apply)
Employment history
Please list the number of years you’ve had paid work:
Medical and Psychiatric History (check all that apply)
Please list food/medication/other allergies and reactions.
Total # of psychiatric inpatient hospitalizations?
Please list your first hospitalization, including name of hospital and approx. date
Please list your most recent hospitalization, including name of hospital and approx. date
Questionnaires
The following are two surveys and a questionnaire. They are required by one of our funding sources. Please note that your answers to these questions do not affect your acceptance to Community 43.
Please answer the following questions
Not at all/Hardly ever
Somewhat/Some of the time
Mostly
Completely
I get important needs of mine met by my current community
It is important for me to feel a part of a community
How often do you feel that you lack companionship?
How often do you feel left out?
How often do you feel isolated from others?
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Taking everything into consideration, during the past week, how satisfied have you been with your...
Very poor
Poor
Fair
Good
Very Good
Physical health
Mood
Work
Household activties
Social relationships
Family relationships
Leisure time activities
Ability to function in daily life
Economic status
Living/housing situation
Ability to get around physically without feeling dizzy or unsteady or falling
Your vision in terms of ability to do work or hobbies
Overall sense of well-being
Medication
How would you rate your overall life satisfaction and contentment during the past week?
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It is important that all components of this application are completed to the best of your ability. Any missing or incomplete components may delay the application process. In addition, it is helpful to include all documents at the same time by emailing or faxing them to us . (Basic documents listed below)
1) A current Part D (treatment plan or ISP) and current Part E (yearly assessment)
2) A detailed psychiatric assessment, current or updated within last 90 days, signed off by an MD
and/or Nurse Practitioner
3) Copies of all Health Insurance cards
Please allow the Membership Team approximately two weeks to review applications. Please contact the Membership Office at (602)274-7373 if you have any questions. Thank you for applying to Community 43. Referrals may be e-mailed to info@community43.org
Electronic Signature *
Date of application *
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Completed an Intake
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Have you completed the Health Information Exchange (HIE) Signature Form? 
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Have you completed the Acknowledgement and Consent Signature Form? 
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Have you completed the Patient Rights Signature Form? 
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Submit
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