Our Space Membership Application

Membership Application

Our mission is to empower adults, experiencing mental illness, achieve their full potential by providing recovery-oriented programs and services in a safe and accepting environment

Our Space provides community living support services to adults to promote stabilization and
recovery. Our programs offer occupational therapy, peer support, prevocational, educational,
recreational, and psycho-socialization services. All programs are in response to the expressed
needs of the individual and we encourage autonomy among the members we serve.

WHAT WE OFFER
Membership is voluntary and you choose the degree of involvement that works best for you. Some benefits
gained from membership are:

Learn to improve socialization skills
Create and maintain a network of peers
Relax and enjoy healthy, affordable fun
Learn skills through participation in educational groups
Receive support through groups and one-on-one support
Experience community integration
Advocacy and empowerment through integrated services and community resources
Peer Support

CCS Provider
Our Space is a provider of Comprehensive Community Services (CCS). Professional staff work with the
individual’s case manager and Peer Support Specialists to offer person-centered recovery-oriented services.

Member Eligibility Reference

Must be completed by a mental health professional, such as a case manager, social worker, therapist, peer specialist or psychiatrist. Please submit online below or download and remit by email to mweisnewski@ourspaceinc.org or by fax to (414) 414-383-9016

Member Eligibility Reference

Member Applicant Name

Your Name *

First

Last

Name of Reference / Organization *

Reference / Organization Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

What is this individual’s Mental Illness Diagnosis?

Our Space members are not supervised at all times, are voluntary and members are able to leave the facility at any time. Do you have any concerns or foresee any issues regarding this individual’s participation in this type of program?

Is there anything Our Space should be aware of regarding this individual’s capacity to interact with others in a social setting, any behavioral concerns or triggers?

Any additional information that would be helpful for the staff to know:

Signature

Date

Phone

Membership Application

Our mission is to empower adults, experiencing mental illness, achieve their full potential by providing recovery-oriented programs and services in a safe and accepting environment

Apply Online

Member Eligibility Reference

Must be completed by a mental health professional, such as a case manager, social worker, therapist, peer specialist or psychiatrist. Please submit online below or download and remit by email to mweisnewski@ourspaceinc.org or by fax to (414) 414-383-9016

Member Eligibility Reference