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.

1a. First Name*

1b. Last Name*

1c. Date of Birth*

1d. Email Address*

1e. Phone Number*

1f. Mailing Address*

1g. City*

1h. State*

1i. Zip*

1j. Please select the option that best describes the type of application you are submitting:*First time applicationReapplication - have been approved in the pastReapplication - have not been approved in the past

2a. Do you live in San Miguel County?*YesNo

2b. Is your physical address the same as your mailing address?YesNo

2c. Physical Address

2d. City

2e. State

2f. Zip

3a. Do you work in San Miguel County?YesNo

3b. Employer Name

3c. Primary Worksite Address

3d. City

3e. State

3f. Zip

You must either live or work in San Miguel County to be eligilbe for this fund. For information on other resources that may be available in your area, please contact the Tri-County Health Network office at (970) 708-7096. Thank you.

Demographics

4a. What gender do you identify as?*

4b. What race do you identify yourself as?*

4c. Please specify your ethnicity.*

4d. What language are you most comfortable speaking?*

4e. What is your veteran status?*

4f. What type of health insurance do you have?*

4g. What is your current employment status?*

4h. What is the highest grade or year of school you have completed?*

4i. How would you rate your personal/family’s financial situation?*

4j. What is the total income for your household per year?*

4k. How many people, including yourself, do you live with?*

4l. What town/city do you live in?*

Financial Information

5a. How many family members, including yourself, depend on your income?*

5b. How many people, including yourself, contribute to your household income?*

5c. What is your total ANNUAL household income?*

5d. Is anyone who contributes to your household income self-employed?*YesNo

5e. Does your household income fluctuate month-to-month?*YesNo

5f. Please indicate your monthly household income?

*Provide projections as necessary

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sept

Oct

Nov

Dec

5g. Please indicate the reasons why you need financial aid

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.

7a. Would you like a Tri-County Health Network Care Coordinator to contact you for assistance with other needs? (e.g. health insurance, food assistance, etc.)YesNo

7b. Please indicate the best method to contact you:EmailPhone

8a. Do you have a current provider/therapist?YesNo

8b. Provider / Therapist Name

8c. Provider / Therapist Phone

8d. Are you currently a TCHN Teletherapy client?YesNo

If you would like help locating a local Colorado licensed therapist please visit tchnetworkdirectory.org or email us at BHFUND@tchnetwork.org.

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.

9a. Signature*

(Use your mouse or trackpad to sign.)

9b. Name*

9c. Today's Date*

10a. How did you hear about this fund?*

Please tell us how you heard about this fund.

10b. Please specify: