Anyone who lives or works in San Miguel County is eligible to receive a scholarship towards six therapy sessions. Those at or below a certain income level may be eligible for six additional sessions, for a total of 12 in 2024. Please complete the application below to apply for a financial scholarship. Your completed application will be reviewed to determine your scholarship eligibility.

If you are 18 or under and attend a San Miguel school, please use our Youth Fund Application instead.

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*

Proof of Income

Proof of income is not required to be eligible for your initial six sessions. You may skip this section if you would only like to apply for six sessions. If you would like to be eligible for an additional six sessions (12 sessions total in 2024), you must submit proof of 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.

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.

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:

Behavioral Health Fund Application

Other members of household applying for scholarships

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

Social Determinants of Health Screener

Financial Information

Proof of Income

Electronic Signature Agreement