Montrose & Delta Recovery Access Fund (RAF)

The Montrose & Delta Recovery Access Fund (RAF) is intended to help those living and/or working in Montrose or Delta Counties to be able to afford individual mental health counseling/therapy services related to substance use concerns and recovery. 2024 Recovery Access Fund-Applications being accepted starting June 10, 2024

1a. First Name*

1b. Middle Initial

1c. Last Name*

1d. Date of Birth*

1d. Email Address*

1e. Phone Number*

1f. Physical Address*

1g. City*

1h. State*

1i. Zip*

1j. Have you experienced or are you worried about your substance use or misuse?:*YesNo

1k. If not, please specify why you are applying for this fund?

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?*

5u. Would you like to be contacted about enrolling in Medicaid/Health Insurance or SNAP?YesNo

Financial Information

The Recovery Access Fund helps cover those living or working in Montrose or Delta County who are working towards or in recovery from substance misuse, 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?*

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 how financial aid would help with substance use prevention

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: