form-test

    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 (see Sliding Scale below). 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 from now until the end of 2022 unless your income, residence, or place of work changes.

    sliding-scale

    YesNo

    YesNo

    YesNo

    Demographics

    FemaleMaleTransgender FemaleTransgender MaleGender Variant/Non-ConformingIntersexQueerNot ListedChoose not to answer

    American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Pacific IslanderWhite or CaucasianMore than one raceNot ListedChoose not to answer

    Latinx/HispanicNon-Latinx/HispanicChoose not to answer

    EnglishSpanishOtherChoose not to answer

    Active Duty MilitaryReservistVeteran (Prior Service)Veteran (Retired)Not a VeteranChoose not to answer

    Medicaid onlyEmployer-sponsored insuranceIndividual insuranceMedicare only/Medicare with supplementalMedicare/Medicaid dual coverageCICPNone/uninsuredDon’t knowChoose not to answer

    Full-time employedPart-time employedSeasonal/temporary employmentSelf-employedContractorStudentHomemakerRetiredUnemployed, looking for workUnemployed, not looking for workDisabledChoose not to answer

    No formal educationSome formal education, no high school diploma/GEDHigh school diploma/GEDTrade/vocational schoolAssociates degreeBachelors degreeGraduate schoolChoose not to answer

    ExcellentGoodFairPoorChoose not to answer

    Less than $9,999$10,000-$14,999$15,000-$19,999$20,000-$24,999$25,000-$34,999$35,000-$49,999$50,000-$74,999$75,000 or moreDon’t know/UnsteadyI choose not to answer

    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)

    Email these documents along with your application 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)


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    EmailPhone

    YesNo

    YesNo

    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.

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