STEPS Specialty Provider Qualifications Checklist

To add or modify the services that your organization is qualified/licensed/certified to provide, please complete and submit this form along with the attached signature sheet.
List one county per line
Populations Served

Please check all areas your agency has training, qualifications, licenses and/or certifications for services that your agency wishes to provide to STEPS program participants.

Please acknowledge the following: I understand that our agency must ensure that there is no conflict of interest directing participants to our agency or organization without considering other service providers. Our agency cannot provide services for family members, relatives or friends of employees or allow family members or relatives to provide STEPS services for participants.
Please download and sign the below STEPS Provider Checklist Signature Sheet and upload the signed and dated sheet in the file upload field.