MH C.H.A.M.P. Application Form

Congratulations on being a MH C.H.A.M.P., taking steps to improve the well-being of yourself and others and reducing stigma. This application form can be completed to show your efforts as an MH C.H.A.M.P. Please complete all the information below including a description of ways you are an active MH C.H.A.M.P. Approved applications will receive a $20 My Health Pay Reward*! (For NH Healthy Families members only).

Member Information * Required

Today’s Date *

First Name *

Birthdate *

City *

Zip Code *

Last Name *

Mailing Address *

State *

Email *

Tell us about what C.H.A.M.P. actions below you are taking:

Communicate – Stay connected by talking to others. Learn about communication skills at verywellmind.com.

Help yourself – Seek help to make yourself feel better by going to therapy, talking to friends who understand, or joining a group in your area.

Achieve a wellness goal – Think about what interests you and what you need. Then, set a goal for your well-being.

Make a commitment to learn – Attend a training, session, program, or webinar about mental health.

Promote MH resources – Spread the word about programs and resources that help with mental health.

I hereby attest that I am an active MH C.H.A.M.P. Please provide a brief description of how you are an MH C.H.A.M.P. *

*Completing this form does not guarantee a reward. Each submission will be reviewed prior to earning the My Health Pays** MH C.H.A.M.P. Reward.

If you need immediate assistance with behavioral health needs please call/text NH Rapid Response Access Point at 833-710-6477.

**Some restrictions and limitations apply. Each Member can earn up to $250 in cash and non-cash goods and services through June 30 each year.

Hey kids!
Do you know about our Healthy Kids Club? It’s available for NH Healthy Families members 12 years old and younger. Kids Club members can learn healthy eating and exercise tips, and join in fun activities and events throughout the year. There is no cost to join! Learn more.