Apply for Membership

New member application

Thank you for your interest in joining the Academy! To apply for membership, complete the form below as thoroughly as possible. This form is confidential and will be sent over a secure connection.

Estimated time to complete: 45 minutes
Please note: This application must be completed in one sitting.

Alternatively, you can download the PDF, print our new member application and return it to us by regular mail, confidential fax, or drop it off at one of our locations.

For assistance, contact our Enrollment Coordinator.

What you will need:

Personal information
Housing and transportation information
Employment information
Income information
Medical information
Provider information

Note: If you are a mental health professional and would like to refer someone for membership, please visit: new member referral.

Progress:

New member application

Step 1 of 6: Personal information

* Preferred name

* First name

Middle name

* Last name

Social Security #

* Gender identity

Primary language

Are you proficient in English?

* Date of birth

* Place of birth

* Phone

* Email

Physical address

* Street address

Apartment/unit #

County

* City

* State

* Zip

Mailing address (if different)

Street address

Apartment/unit #

County

City

State

Zip

Family contact

Name

Relationship

Street address

Apartment/unit #

City

State

Zip

Phone

Background

* Marital status

* Race

* Ethnicity

* Education (highest completed)

* Military veteran status

Legal history

* Have you ever been arrested?

* Have you ever been incarcerated?

* Have you ever been convicted of a misdemeanor?

* Have you ever been convicted of a felony?

* Have you ever physically injured anyone?

If you answered yes to any of these questions, please indicate dates, causes and outcome below:

Legal history details

Membership goals

Friendship/community

Employment

Education

Housing

Health and wellness

Benefits care/coordination

Other goals

Referral source

* How did you hear or learn about the Academy?

Progress:

30%

New member application

Step 3 of 6: Employment

* Have you worked in the past 12 months?

* Current employment status:

Additional work info

Future goals (check all that apply):

Obtain part-time job

Obtain full-time job

Not seeking paid work

Maintain current job

* Estimate number of paid jobs you have had

* Estimate number of years you have worked for pay

* Are you involved with VR (Vocational Rehabilitation)?

* Are you involved in Supported Employment?

Progress:

50%

New member application

Step 4 of 6: Income

Enter monthly amounts for all income sources that apply:

Employment wages

Retirement

SSI

SSDI

Social Security

Veterans benefits

Public assistance

Spouse

Family support

Friend support

Other

Your total monthly income: $0

If you receive governmental benefits, do you have a Representative Payee?

Progress:

65%

New member application

Step 5 of 6: Medical

Check all that apply:

Asthma

Chronic pain

Diabetes

Hypertension

Physical impairment

Recent surgery

Seizure disorder

Visual impairment

Other

Allergies/medical alert

* Hearing ability

Medical insurance

Please provide insurer name and policy number if you have insurance. (Medical insurance is not necessary for membership)

Straight Medicaid

Provider

ID #

Effective date

Medicare

Provider

ID #

Effective date

Private insurance

Provider

ID #

Effective date

If Medicaid Managed Care, please include name of managed care company:

Company name

Medications

Recent hospitalizations

Additional medical history

* Do you have a past history of dependency on alcohol or other drugs?

* Have you ever been in treatment for use of alcohol or other drugs?

* Are you currently in treatment or in a support group?

Progress:

80%

New member application

Phone

FINAL STEP: Once this form is submitted, you will be unable to go back and edit your entries. This form is confidential and will be sent over a secure connection. By submitting this form, you certify that all information stated on this application is correct.

You're invited!

Stop by and see what we're all about

We welcome you to come take a tour of the Academy. See the teams in action and enjoy a healthy lunch prepared onsite. To better accommodate you, appointments are preferred.

Schedule a tour Contact us

Sarasota Campus

1910 Glengary St.
Sarasota, FL 34231
(941) 921-9930

Bradenton Campus

601 12th Street West
Bradenton, FL 34205
(941) 929-2800

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Apply for Membership

What you will need:

Progress:

New member application

Step 1 of 6: Personal information

Physical address

Mailing address (if different)

Family contact

Background

Legal history

Membership goals

Referral source

Progress:

New member application

Step 2 of 6: Housing and transportation

Transportation

Progress:

New member application

Step 3 of 6: Employment

Current employer

Additional work info

Progress:

New member application

Step 4 of 6: Income

Your total monthly income: $0

Representative Payee

Progress:

New member application

Step 5 of 6: Medical

Medical insurance

Medications

Recent hospitalizations

Additional medical history

Progress:

New member application

Step 6 of 6: Provider information

Case Worker/Manager

Therapist

Psychiatrist

Primary Care MD

Other

Stop by and see what we're all about

Sarasota Campus

Bradenton Campus