CM-0052, Counseling Contract Application

Michigan Department of Health and Human Services (MDHHS)

(Revised 10-24)

SECTION 1

Directions: If applying as an individual, complete Section 1A - Individual. If applying as an organization, complete Section 1B - Organization.

Are you applying as an individual or organization? Individual Organization

section 1a – individual

Name of Individual	Prior Names (marriages, divorce, etc.)

Date of Birth	Race

Section 1B – organization

Name of Organization

Names of individuals providing services through the organization	Prior Names (marriages, divorce, etc.)	Date of Birth	Race

SECTION 2 – contractor information (must be completed for individual or organization)

Provide the SIGMA customer number below for payment purposes.

SIGMA Customer Number

Mailing Address

City	State	Zip + 4

Contact Person	Telephone

Email Address

1. Neither you nor any of your employees or sub-contractors are providing services under another counseling contract through the State of Michigan.	True False
2. You are not an employee of the State of Michigan. (If false, provide copy of approved Supplemental Employment form.)	True False

List ALL counties you are able to provide counseling services in.

If you have the capacity to provide bilingual or multi-lingual services, indicate the languages other than English.

Provide the address(es) of location(s) where services will be provided (if different than above).

section 3 – Include the following required documentation for each person who will be providing service under the contract:

1. A copy of each person's master's level State of Michigan license to provide counseling or psychotherapy.
Note: If providing substance abuse counseling, a current copy of each person's certification through the Michigan Certification Board of Addiction Professionals (MCBAP) is required.
2. A copy of the social security card for each counselor providing services. Proof of federal ID# must be provided for organizations.
3. A copy of the driver's license or state identification for each counselor providing services.
4. A copy of the completed Children's Protective Services History Review from (CWL-4624) for each counselor providing services under the contract.
NOTE: The CWL-4624 must be submitted to mdhhs-cpsbackgroundchecks@michigan.gov with a copy of the individuals driver's license or state ID.

Check next to each service you intend to provide under this contract

Counseling Services – Individual/Family	$81.50/Unit
Counseling Services – Group	$173.00/Unit

Ancillary Services –when authorized by MDHHS referring worker to include: off-site observations at schools or parent/child visits; family meetings; court preparation and participation, travel time; and preparation or review of written reports other than those required by the contract. Mileage reimbursement will be paid for services provided off-site and for any of the Ancillary Services listed above.	$31.50/per hour

NOTE: The unit definition for Individual/Family Counseling services: One unit equals one session of not less than 50 minutes of a provider’s time in a face-to-face or via telehealth technology counseling session with a referred client and/or family members and/or other person(s) significant to the client (if specified in the MDHHS referral) at a confidential space such as the Contractor’s usual place of business, the client’s home or, with prior MDHHS approval, at a mutually agreed upon site.
The unit definition for Group Counseling services is: One unit equals 1 ½ hour of a provider’s time in a face-to-face or via telehealth technology group counseling session to a group of referred clients. Partial units are allowed per contract language. Contracts do not permit billing for missed appointments.
All new contracts are given an initial total contract value, however, payments are based on actual services provided. Contract expenses will be monitored and the contract value may be adjusted by amendment if needed. All required information must be received before a contract can be processed.
If additional therapists are added to the contract as sub-contractors, they may not provide services until written approval is received from the applicable Business Service Center (BSC).
Use your mailing address from page 1 of this application to determine which Business Service Center (see map on page 3) you send the application and credentials to for processing.

The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group on the basis of race, national origin, color, sex, disability, religion, age, height, weight, familial status, partisan considerations, or genetic information. Sex-based discrimination includes, but is not limited to, discrimination based on sexual orientation, gender identity, gender expression, sex characteristics, and pregnancy.

Business Service Center 1	Business Service Center 2	Business Service Center 3	Business Service Center 4	Business Service Center 5
Email to: BSC-1-Contracts@ michigan.gov	Email to: BSC-2-Contracts@ michigan.gov	Email to: BSC-3-Contracts@ michigan.gov	Email to: BSC-4-Contracts@ michigan.gov	Email to: BSC-5-Contracts@ michigan.gov

Reach out to the appropriate BSC via email. Arrangements can be made via email to discuss a counseling contract via telephone.