Youth Fund Application – Tri-County Health Network

The San Miguel Youth Fund pays $110 towards any youth therapy session with a state registered provider. Any youth who attend Norwood Public Schools, Telluride Public Schools or Telluride Mountain School are eligible for the fund. If youth have a parent working in San Miguel County but they live outside of San Miguel they are also eligible. If you are approved for this scholarship, you can use it through the end of 2024 or until funds run out.

First Name*

Middle Name

Last Name*

Date of Birth*

Your Email*

Phone*

Preferred Language*

Home Address*

Gender*

Emergency Contact Name

Emergency Contact Phone

Emergency Contact Relationship

School Attending*

Do you have a parent living or working in San Miguel County?*YesNoI’m not sure

Are you currently seeing a therapist and if so, who?* YesNo

Who is your therapist?

The following questions ask for information about your parents, including their contact information. If you are 12 or over, Colorado does not require your parents’ consent for you to receive therapy services. If you are 12 or over, your parents' information is not required for you to receive a scholarship through the San Miguel Youth Behavorial Health Fund.

Is it okay to contact a parent to discuss your options for therapy?YesNo

Parent Name

Parent Phone

Parent Email