RAF Health Fund Application

West End & Delta Recovery Access Fund (RAF)


The West End & Delta Recovery Access Fund (RAF) is intended to help those living and/or working in Delta County and the West End of Montrose 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



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    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.

    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.

    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.

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    Financial Information

    The behavioral health fund accepts anyone who lives/works in San Miguel, 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.

    *Provide projections as necessary

    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:

    • Last Years Tax Return

    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.

    7a. Yourself

    Pay Stubs for the Last Two Months of WorkProof of UnemploymentProfit and Loss Statements (if self-employed)

    7b. Contributor #2

    Pay Stubs for the Last Two Months of WorkProof of UnemploymentProfit and Loss Statements (if self-employed)

    7c. Contributor #3

    Pay Stubs for the Last Two Months of WorkProof of UnemploymentProfit and Loss Statements (if self-employed)

    7d. Contributor #4

    Pay Stubs for the Last Two Months of WorkProof of UnemploymentProfit and Loss Statements (if self-employed)


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    Electronic Signature Agreement

    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. 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.

    (Use your mouse or trackpad to sign.)

    Please tell us how you heard about this fund.

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