OLIVIA’S FUND SCHOLARSHIP APPLICATION Sponsored by Eagle Valley Behavioral Health

The Olivia’s Fund Scholarship Program is available to all individuals who live or work in Eagle County, Colorado and face a financial barrier to seeking behavioral health treatment. To apply for financial assistance, please complete the following application. Once your application is approved, you will be informed of the next steps and provided with a unique patient ID to send to your behavioral health provider to schedule free or reduced behavioral health appointments. Please complete the following form and email it to eaglevalleybh@vailhealth.org

Are you applying for a dependent child (under the age of 16)? □ Yes □ No If yes, please be sure to complete section #1 for yourself and section #2 for your child. 1. Applicant Information: First & Last Name: _______________________________________________ Date of Birth: ___________________ Phone Number: _________________________ E-mail address: __________________________________________ Zip Code: ______________ Gender: □ Female □ Male □ Other: _________________ Race/Ethnicity: □ White or Caucasian □ Hispanic or Latino □ Black or African American □ Asian

□ Native American or Alaska Native □ Native Hawaiian or other Pacific Islander □ Another race: _____________

Household Annual Income*: ________________ How many people are in your household*? ___________ *The above questions are used to determine financial eligibility. Olivia’s Fund scholarship eligibility is set at 600% of the Federal Poverty Level. Marital Status: □ Single □ Married □ Living Together

□ Separated □ Divorced □ Widowed

Employer Name: ____________________________________________ Do you have medical insurance? □ Yes □ No

If you HAVE insurance: Insurance Provider __________________________________ Can you afford the costs (copay and deductible) associated with your insurance plan? □ Yes □ No Have you attempted to schedule a behavioral health appointment with Colorado Mountain Medical (CMM), Mountain Family Health Centers (MFHC), or Mind Springs (those providers in the community who accept insurance)? □ Yes □ No

Please describe why you do not wish to seek services at CMM, MFHC or Mind Springs?

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If you DO NOT have insurance, I am uninsured because: □ I am not eligible □ I don’t know how to get insurance □ I can’t afford health insurance □ I don’t need medical insurance □ I lost my job □ I lost Medicaid or other coverage □ Other: __________________________________________

2. Child’s Information Complete this section only if the scholarship recipient is for a minor child. Child’s First & Last Name: ___________________________________ Child’s Date of Birth: ____________ Child’s Gender: □ Female □ Male □ Other: ____________ Child’s Race/Ethnicity: □ White or Caucasian □ Hispanic or Latino □ Black or African American □ Asian

□ Native American or Alaska Native □ Native Hawaiian or other Pacific Islander □ Another race: _____________

3. Provider Preferences: Name of a specific therapist preferred (if applicable) __________________________________ □ Male Provider □ Female Provider

Preferred Area(s) of Expertise:

● Abuse ● Addiction ● Anxiety ● Aggression ● Attachment

● Child ● Couples ● Depression ● Divorce ● Domestic Violence

● Drug and Alcohol ● Eating Disorders ● Family ● LGBTQ+ ● Teen

Other:_________________________________________________________________

4. Program Requirements By initialing next to each bullet point, I understand and agree to the following:

________I confirm that paying for therapy presents a significant financial burden for me, that my current insurance or lack of it is an impediment to adequate care, and that I am not able to pay for care.

________ I confirm that I live and/or work in Eagle County, Colorado. I understand that if I do not live or work in Eagle County that I am not eligible for the Olivia’s Fund Scholarship Program.

________Eagle Valley Behavioral Health’s Scholarship Program will provide financial assistance for 6 (six) free or reduced cost behavioral health sessions with a licensed provider of your choice (as long as the provider is pre-approved by the Olivia’s Fund Scholarship Program).

________If I have insurance, my insurance will be billed as normal, and the Olivia’s Fund Scholarship Program funds will only apply for any extra amount that is due, over and above what my insurance pays for.

________If I need to cancel or reschedule my appointment, I understand that it is my responsibility to call my therapist and inform them at least 24-48 hours before my appointment.

________Failure to show up for appointments (two or more) may cause me to forfeit my scholarship.

_______ I understand that if I do not make an attempt to schedule an appointment with a participating behavioral health provider within 30 days of being approved by the Olivia’s Fund Scholarship Program, my scholarship will expire and I will be required to reapply to the scholarship program.

________I understand that Eagle Valley Behavioral Health does not evaluate, endorse or vouch for services of mental health providers that participate in the Olivia’s Fund Scholarship Program. I also acknowledge that Eagle Valley Behavioral Health does not schedule appointments, and it only provides access to providers who participate in the Scholarship Program, and provides financial assistance for behavioral health care with currently licensed mental health providers. It is my responsibility to investigate my chosen provider, determine if the provider is a good fit, and schedule appointments with the selected provider of my choice. If I am not comfortable with my therapist, I can reach out to Eagle Valley Behavioral Health to help connect me with another therapist.

_______ If my application is accepted, as an Eagle Valley Behavioral Health Olivia’s Fund Scholarship Program recipient, I understand that I am required to participate in a final feedback questionnaire that will be sent to me via email at the end of my therapy sessions. (These evaluations help Eagle Valley Behavioral Health to make system improvements and ensure continued funding. We appreciate your time to fill out these very important evaluations).

5. Release of Information:

If my application is approved, by signing this form, I authorize Eagle Valley Behavioral Health to share personally identifying information with participating Olivia’s Fund Scholarship Program licensed clinical providers and community navigators housed at Eagle County Community Paramedics, and such providers to share personally identifying information back to Eagle Valley Behavioral Health, such as name, address, date of birth, and number of visits, so that Eagle Valley Behavioral Health can manage the payment of the scholarship funds to my provider. While none of my medical records with my provider should be shared with Eagle Valley Behavioral Health, I understand that by being an Olivia’s Fund Scholarship Program recipient, it is understood that Eagle Valley Behavioral Health will understand that my visits with my provider might deal with underlying mental health and/or substance abuse issues. This authorization will expire once my, up to six (6), treatment sessions have been exhausted and Eagle Valley Behavioral Health has fulfilled all scholarship payment obligations to my provider under the Scholarship Program. In addition, Eagle Valley Behavioral Health will exchange info with the therapist of your choice to connect you to care, track sessions for billing, and to execute a final evaluation.

_____________ __________________________________ _______________ Recipient or Parent (Applicant) Signature Date _____________ __________________________________ Recipient or Parent (Applicant) Printed Name