Behavioral Health Fund Application

    The San Miguel Behavioral Health Solutions Panel (Panel) created the Behavioral Health Fund (SMBH 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 for counseling/therapy based on current yearly household income (see Sliding Scale below). Individuals that live or work in San Miguel County are elligible for up to $110 per session for up to 6 counseling/therapy sessions per calendar year. If your household income is less than or equal to 400% of the federal poverty level (FPL), you may be eligible for an additional 6 sessions at either $85 or $100 per session. Your therapist must be licensed in the state of Colorad and must agree to bill the Panel for services provided through the TCHnetwork website.

    This application is good from now until the end of 2023 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


    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 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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