Youth Fund Application – Thrive Community Health Network

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

First Name*

Middle Name

Last Name*

Date of Birth*

Your Email*

Phone*

Is it okay to leave a voicemail?*YesNoI’m not sure

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

If your therapy or counseling is related to substance use challenges or recovery from substances, then you may be eligible for up to 12 additional sessions through our Recovery Access Fund. Please answer the following question for our team to help maximize your scholarship potential.

Is your request for counseling related to substance use or recovery?*YesNo

Release of Information Consent
By submitting 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 Thrive Community Health Network and its partners from any liability related to the sharing of this information.