The Voucher Program supports delivery of mental health, substance use disorder, and peer recovery support services for individuals who have been impacted in some way by a weather-related disaster or by Covid-19. Only South Dakota residents are eligible for the voucher program, and financial eligibility will also apply.
Provider Enrollment Form
Please complete the form below to enroll as a participating provider in the Behavioral Health Services Voucher Program, managed by the Division of Behavioral Health, SD Department of Social Services.
Name
First Name
Last Name
Applicable Credentials
Licensed Clinical Social Worker (LCSW) - Personal Independent Practice (PIP)
LCSW working on PIP
Clinical Nurse Specialist (CNS) - Mental Health (MH)
Licensed Professional Counselor (LPC) - MH
LPC working on MN
Marriage and Family Therapist (MFT)
Licensed Psychologist (LP)
Psychiatrist
Advanced Practice Provider (APP)
Other
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Email
Phone Number
-
Area Code
Phone Number
Back
Next
Applicable Services
The following section captures information about your licensure and experience in selected evidence-based practices.
South Dakota License Number
Licensing Agency
Upload a copy of Licensure or Certification
Browse Files
Cancel
of
Type(s) of services you are able to provide (select all that apply) :
Substance Use Disorder Treatment
Mental Health Counseling
Peer Support Services / Coaching - Substance Use Disorders
Other
If other, please list
Type(s) of therapy(ies) you are experienced in (select all that apply):
Cognitive Behavioral Therapy (CBT)
Cognitive Behavioral Therapy - Post Disaster (CBT-PD)
Dialectic Behavior Therapy (DBT)
Other
If other, please list
Type(s) of therapy(ies) you would like more training in (select all that apply):
CBT
CBT-PD
DBT
Other
If other, please list
Specialty Area(s) of Practice (if applicable):
Description of experience working with individuals and their families who have been impacted by a natural disaster:
Back
Next
Terms & Conditions
The following expectations must be agreed to upon submission of your enrollment application to participate as a voucher program provider. For specific questions on any of these elements, please contact Rachel Oelmann, Program Director, at 605-321-7262 or via email at rachel@sageprojectconsultants.com.
By participating as an authorized provider through the SD DSS Behavioral Health Services Voucher Program, I agree to:
provide treatment services within 15 days of referral.
send invoices for payment within 30 days of service delivery, and acknowledge that submission of invoices for payment without the required attachments may result in delayed processing.
complete all required data collection elements, including compliance with the Government Performance and Results Act questionnaires to be administered to clients served at the point of intake, at six months post-intake, and at discharge, using the provided tool (web-based Discretionary Grant Management Information System).
notify the program administrator immediately if my ability to deliver services or licensure changes.
Provider Signature
Submit
Clear All Questions
Print
Should be Empty: