CRF ARF Mental Health Care Application

CRF's Angel Relief Fund offers assistance for mental health treatment to Colorado restaurant industry employees. CRF provides mental health care grants up to $1,000, paid directly to mental health care providers.

CRF has partnerships with Khesed Wellness and Teladoc, but will fund care from other mental health care providers as well. Applicants are asked to specify their provider; if the provider is not Khesed or Teladoc, they must meet the below criteria. CRF will then invite the provider to apply for reimbursement of care on behalf of the approved applicant, up to $1,000. Invoices may be redacted - CRF will not ask for diagnosis information.

Applicants are eligible to receive only one grant per person.

CRF will keep all information confidential and will not receive any confidential health information from the provider.

Types of care we cover:

Mental Health Care Provider Requirements:

•Virtual out-patient treatment

•In-person out-patient treatment

•In-patient treatment

•Licensed provider registered with the Colorado Department of Regulatory Agencies (DORA)

•Holds one of the following licenses:

• LPCC - Licensed Professional Counselor Candidate
• LPC - Licensed Professional Counselor
• LAC - Licensed Addiction Counselor
• MSW - Master of Social Work
• LCSW - Licensed Clinical Social Worker
• LMFT - Licensed Marriage Family Therapist

Applicant Name: *

First Name Last Name

Application Date: *

Date

Mailing Address: *

Street Address

Apt. #

City State / Province

Postal / Zip Code Country

Cell Phone Number: *

Area Code Phone Number

Alt. Phone:

Area Code Phone Number

E-mail: *

Where the confirmation will be send to

Best way to reach applicant? *

Mental Health Care Provider: *

Khesed Wellness Teladoc Other (provide details below)

Mental Health Care Provider Name (if not Khesed/Teladoc)

Mental Health Care Provider Email Address (if not Khesed/Teladoc)

Mental Health Care Provider Phone Number (if not Khesed/Teladoc)

Gender (optional, for reporting purposes only):

MALE FEMALE NON-BINARY OTHER PREFER NOT TO ANSWER

Race (optional, for reporting purposes only):

AMERICAN INDIAN/NATIVE AMERICAN ASIAN BLACK/AFRICAN AMERICAN HISPANIC/LATINO WHITE/CAUCASIAN PACIFIC ISLANDER OTHER PREFER NOT TO ANSWER

Restaurant or F&B Hospitality Business Name: *

Work Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Restaurant or F&B Hospitality Business Phone Number: *

Area Code Phone Number

Applicant date of hire:

Date

Applicant date of termination: (If applicable)

Date

Manager Name (for employment verification purposes only - CRF will not share application information): *

First Name Last Name

Manager Email (for employment verification purposes only - CRF will not share application information): *

example@example.com

Cell Phone Number: *

Area Code Phone Number

Tell us about your position (check one): *

FOH BOH

Duties: *

In order to have your application reviewed, you must upload the following:

Proof of Colorado residency (Required - CO Driver’s License, CO I.D., signed lease document, or any bill from electric, energy or water)
Proof of current employment in a Colorado restaurant or F&B hospitality business by way of your last two paystubs. (Required)

Upload proof of Colorado residency (Required) *

Browse Files

Upload Proof of current or past employment in a Colorado restaurant or F&B hospitality related business by way of your last two pay stubs or W-9. (Required) *

Browse Files

E-Signature: *

I certify that the information contained in this application is true, correct and complete. By signing the certification below, I authorize CRF to request additional information as deemed necessary in the process of reviewing my grant request. I understand that this authorization is voluntary and may be revoked at any time by giving written notice of my revocation to the organization contact listed in this application.

CRF Mental Health Care Grant Application