Applications for 2025 Behavioral Health Fund Scholarships are now open. If you receive a scholarship, you can begin using it on January 1^st, 2025.

Anyone who lives or works in San Miguel County is eligible to receive six sessions through the Behavioral Health Fund. Depending on your income, you may be eligible for an additional six.

If you would like assistance establishing long-term solutions to accessing behavioral health care, TCHN’s Care Coordination team may be able to help. Please reach out to cc-referral@tchnetwork.org or call 970-708-7096.

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

Other members of household applying for scholarships

11a. Do you have any other household members applying?YesNo

11b. Other 1 First Name

11c. Other 1 Last Name

11d. Other 1 Date of Birth

11e. Other 2 First Name

11f. Other 2 Last Name

11g. Other 2 Date of Birth

11h. Other 3 First Name

11i. Other 3 Last Name

11j. Other 3 Date of Birth

11k. Other 4 First Name

11l. Other 4 Last Name

11m. Other 4 Date of Birth

11n. Other 5 First Name

11o. Other 5 Last Name

11p. Other 5 Date of Birth

11q. Other 6 First Name

11r. Other 6 Last Name

11s. Other 6 Date of Birth

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

Providing information on your demographics provides valuable information on what sectors of our community are utilizing the Fund and seeking behavioral health services. Your answers will not affect the likelihood of your application's acceptance. You may choose not to answer any or all questions.All answers will remain confidential.

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?*

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

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

Social Determinants of Health Screener

The below questions are asked so that we can provide services and resources in other areas of your life where you may need/want support. Your answers will not affect the likelihood of your application's acceptance and they will not be shared with your behavioral health provider. If you consent, a care coordinator from TCHN may reach out to you with additional resources. You may choose not to answer any or all questions by selecting "Choose Not To Answer" in the drop-down menu. All answers will remain confidential.

5a. What is your living situation today?*

5b. Think about the place you live. Do you have problems with any of the following? (select all that apply)*Pests such as bugs, ants, or miceSmoke detectors missing or not workingOven or stove not workingMoldLead paint or pipesLack of heatWater leaksNone of the aboveI choose not to answer.

5c. Within the past 12 months, you worried that your food would run out before you got money to buy more.*

5d. Within the past 12 months, the food you bought just didn't last and you didn't have money to get more.*

5e. In the past 12 months, has lack of reliable transportation kept you from medical appointments, meetings, work or from getting to things needed for daily living (food, job interview, child care)?*

5f. In the past 12 months has the electric, gas, oil, or water company threatened to shut off services in your home of where you live?*

5g. Do problems getting child care make it difficult for you to work or study?*

5h. How many times have you received care in an emergency room (ER) over the last 12 months?*

5i. In the last 12 months, have you needed to see a medical provider (doctor, dentist, mental health, optometrist, specialist), but could not because of how much it cost?*

5j. How often do you have a problem understanding what is told to you by a medical provider about your health or a medical condition?*

5k. How confident are you in filling out medical forms by yourself?*

5l. How often does anyone, including family and friends, insult or talk down to you?*

5m. How often does anyone, including family and friends, scream or curse at you?*

5n. How often does anyone, including family and friends, threaten you with harm?*

5o. How often does anyone, including family and friends, physically hurt you?*

5p. In the past 12 months, how often do you participate in group activities like going to church, volunteering, attending a meeting of an organized group (book club, Rotary, veterans’ group)?*

5q. If your family suddenly had a crisis or needed money for an unexpected expense, like a car repair or serious illness, would you have someone you could count on for help?*

5r. How often do you feel lonely or isolated from those around you?*

5s. Stress is when someone feels tense, nervous, anxious, or can’t sleep at night because their mind is troubled. How stressed are you?*

5t. Do you have concerns about immigration for you or your family members?*

Care coordinators can help with food and housing resources, immigration assistance, domestic violence resources, and more.

5u. Care coordinators can help with food and housing resources, immigration assistance, health insurance, domestic violence resources, and more. Would you like a Tri-County Health Network Care Coordinator to contact you for assistance with other needs?YesNo

5v. Please indicate the best method to contact you:EmailPhone

Financial Information

The behavioral health fund accepts anyone who lives/works in San Miguel, regardless of income, for an initial six sessions. Your reported income will not affect your application's acceptance for an initial six sessions. Dependent on income, you may be approved for an additional six sessions.

6a. How many family members, including yourself, depend on your income?*

6b. How many people, including yourself, contribute to your household income?*

6c. How would you rate your personal/family’s financial situation?*

6d. What is the total income for your household per year?*

6e. Is anyone who contributes to your household income self-employed?*YesNo

6f. Does your household income fluctuate month-to-month?*YesNo

6g. Please indicate your monthly household income?

*Provide projections as necessary

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sept

Oct

Nov

Dec

6h. Please indicate the reasons why you need financial aid

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 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.

Release of Information Consent
By signing this application, I understand that my information may include protected health information. I authorize the release of my information to any person or agency necessary to meet my service needs, including, but not limited to, vendors and partner agencies. This information will be used solely for the purpose of assessing, arranging, and meeting my individual service needs. I release Tri-County Health Network and its partners from any liability related to the sharing of this information.

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: