Behavioral Health Fund Application

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

    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 this application below to apply for a financial scholarship in the form of a copay. Your completed application will be reviewed to determine your copay for counseling/therapy based on current yearly family income. The Panel will cover the remaining balance of your counseling/therapy session. Your therapist must agree to bill the Panel for services provided. This application is good for one calendar year, starting January 1, 2021, through December 31, 2021, unless your income, residence, or place of work changes.

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    Demographics

    Tri-County Health Network’s programs are funded through grants from different agencies and foundations. To continue to receive funding and offer services in our community, we have to report on the demographics of the people served in our programs. Please help us learn more about our program participants by answering the following questions. You may select “choose not to answer” if you do not wish to provide the information. Thank you!

    2021 Financial Information

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    *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 ***

    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)

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    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. Finally, I understand that there is no guarantee I will receive a financial scholarship.

    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.)

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