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

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

West End & Delta Recovery Access Fund (RAF)

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

Social Determinants of Health Screener

Financial Information

Electronic Signature Agreement