Behavioral Health Fund Application

    The San Miguel Behavioral Health Solutions Panel (Panel) created the Behavioral Health Fund (BH Fund), which is intended to help those living and/or working in San Miguel County to be able to afford individual mental health counseling/therapy services. Please complete the application below to apply for a financial scholarship. Your completed application will be reviewed to determine your scholarship eligibility.

    Applicants can apply for a scholarship of $110 per session for the first 6 sessions regardless of income. Any income levels will be approved for the first 6 sessions but we will still require proof of income for informational purposes. Depending on income qualifications and having a follow-up meeting with the BH fund navigator after the first 6 sessions, scholarship recipients may be eligible for an additional 6 sessions that will also be reimbursed at $110 per session. The applicant is responsible for any additional cost beyond the scholarship amount or the approved number of sessions. Scholarships are good for one calendar year unless there is a change in income, residence, or place of work.

    Your therapist must be licensed in the state of Colorado and must agree to bill the Panel for services provided through the Tchnetwork website. You must be approved prior to starting therapy services.

    This application is good from January 1, 2024 until the end of 2024 unless your income, residence, or place of work changes.

    If you would prefer to complete a paper application you can print out THIS PDF, fill it out by hand, scan it back in, and send the completed document, along with your proof of income documentation, to BHFUND@tchnetwork.org.

    Every section of this application must be completed in its entirety. Incomplete applications will not be considered.

    sliding-scale


    First time applicationReapplication - have been approved in the pastReapplication - have not been approved in the past

    Other members of household applying for scholarships

    YesNo


    YesNo

    YesNo

    YesNo

    Demographics

    Financial Information

    YesNo

    YesNo

    *Provide projections as necessary

    Proof of Income

    You must provide one of the following for EACH person contributing to your annual household income:

    • Pay Stubs for the Last Two Months of Work
    • Proof of Unemployment, as applicable
    • Profit and Loss Statements (if self-employed)

    Each file must be either jpg, jpeg, png, gif, pdf, doc, or docx with a maximum file size of 890KB. If your documents are too large or you are having issues uploading them you can email them as attachments to bhfund@tchnetwork.org. Please be sure to include your name and what each attached document is for.

    6a. Yourself

    Pay Stubs for the Last Two Months of WorkProof of UnemploymentProfit and Loss Statements (if self-employed)

    6b. Contributor #2

    Pay Stubs for the Last Two Months of WorkProof of UnemploymentProfit and Loss Statements (if self-employed)

    6c. Contributor #3

    Pay Stubs for the Last Two Months of WorkProof of UnemploymentProfit and Loss Statements (if self-employed)

    6d. Contributor #4

    Pay Stubs for the Last Two Months of WorkProof of UnemploymentProfit and Loss Statements (if self-employed)


    YesNo

    EmailPhone

    YesNo

    YesNo

    Electronic Signature Agreement

    I certify, to the best of my knowledge, that all information in this application is true and accurate. Furthermore, I agree to inform Tri-County Health Network if my family income, county of residence, or my place of work changes at any point of the year. I understand that there is no guarantee I will receive a financial scholarship. Finally, I understand that, if I receive a financial scholarship, in order for my care to be paid, I authorize my therapist to release the dates/times of my treatment and reason for visit - for payment purposes only. Any personal information that could identify me will be changed before this information is shared with the San Miguel Behavioral Health Solutions Panel Solutions.

    The parties agree that this agreement may be electronically signed. The parties acknowledge that electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability and admissibility.

    (Use your mouse or trackpad to sign.)

    Please tell us how you heard about this fund.

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