Delta, Montrose, Ouray & San Miguel Recovery Access Fund (RAF)

The Delta, Montrose, Ouray & San Miguel Recovery Access Fund (RAF) is intended to help those living and/or working in Delta, Montrose, Ouray or San Miguel Counties to be able to afford individual mental health counseling/therapy services related to substance use concerns and recovery. Applications for 2025 and 2026 Recovery Access Fund Scholarships are now open. Each applicant should fill out an individual application. If you receive a 2026 scholarship, you can begin using it on January 1st, 2026. If you receive a 2025 scholarship, you can use it for sessions occurring between now and December 31st, 2025

I have used RAF in the past.*YesNoI am not sure:

Which Behavioral Health Fund scholarship period are you applying for?*Scholarship for use through December 31Scholarship for use beginning January 1, 2026Both scholarship periodsNot sure - I'd like to speak to a TCHN employee about which scholarship is best for me

1a. First Name*

1b. Middle Initial

1c. Last Name*

1d. Date of Birth*

1d. Email Address*

1e. Phone Number*

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

8b. Provider / Therapist Name

8c. Provider / Therapist Phone

8d. Provider / Email

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

8e. Would you like assistance finding a provider??YesNo

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

Electronic Signature Agreement

9a. Are you applying for:?YourselfDependent

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.

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.

9b. Signature*

(Use your mouse or trackpad to sign.)

9c. Name*

9d. Today's Date*

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

Please tell us how you heard about this fund.

10b. Please specify:

RAF Health Fund Application – 2026

Delta, Montrose, Ouray & San Miguel Recovery Access Fund (RAF)

Demographics

Social Determinants of Health Screener

Financial Information

Electronic Signature Agreement