form-tester


    Eligibility Requirements

    • 18 years old and up (not in another Case Management Program)
    • Uninsured, private insurance, CICP, or Medicare
    • Cannot be on Medicaid, (Medicaid members can be referred to TCHNetwork’s Medicaid Care Coordinator)
    • A patient with the Basin Clinic (there is a plan to expand in the spring to all West End residents)

    When in doubt, ask. Contact Amy Rowan at oc-montrose@tchnetwork.org or 970.614.7311 M-F 8-5 for assistance.



    Verification of Client Consent

    YesNo

    Please inform the client and obtain consent prior to proceeding.



    Referring Party/Agency



    Client Information



    Involved Parties

    Please list spouse, partners, agencies, and other supports that are involved with the client and family.








    If you get a message that says, “There was an error trying to send your message. Please try again later,” just click “Submit” again.

    If you continue to get an error message, or have any other questions please contact Amy Rowan at oc-montrose@tchnetwork.org or 970.614.7311 M-F 8-5 for assistance.

      Organizational Information

      Volunteer Dates, Times, Numbers, and Work Descriptions

      Please provide the info below. If there are different shifts needed or different work requiring different volunteers to be done please complete 1 line item per shift/duty.

      Volunteer Skills and Criteria

      Location of Volunteer Work

      Supervisor Information

      If you get a message that says, “There was an error trying to send your message. Please try again later,” just click “Submit” again.

      If you continue to get an error message, please contact 970.708.7096 M-F 8 -5 for assistance.

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