PSI-SD Doula/Therapy Scholarship Application

It is the mission of the South Dakota Chapter of Postpartum Support International (PSI-SD) to promote awareness, prevention and treatment of mental health issues related to childbearing throughout the state. Throughout 2021, PSI-SD was able to raise money to support families who could benefit from postpartum doula and/or mental health services. We are glad you have reached out in search of such services, thank you for allowing PSI-SD to assist you in this journey! Please complete this form and your application will be submitted to PSI-SD.
Name
Phone
Email
example@example.com
Address
Preferred method of contact
If calling, may PSI-SD leave a voice message?

Yes No
Baby's Name
Baby DOB

Month Day Year
Date
Which service are you applying for?

Postpartum Doula Therapy
Which services are you applying for?

Postpartum Doula Therapy
Have you already chosen a provider?

Yes No

What would you hope to gain through use of the above selected service(s)?
Upon receipt of this application, PSI-SD will review the provided information and will contact you to provide updates to your application status as needed. You will be notified via your preferred method of contact for approval or denial of application. Once the application is processed and you have been notified, PSI-SD will contact the provider to arrange payment for services, if you listed on above. If you have not yet chosen a provider, PSI-SD may assist you in doing so. No finances will be passed directly from PSI-SD to the applicant and payment will be made to the provider after services have been

By signing below, you acknowledge your consent to these terms. You are also granting PSI-SD permission to reach out to the chosen provider on your behalf to arrange for payment of services.
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Signature

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Date

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Date
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