Clinical Privileging Form

CLINICAL PRIVILEGES CLINICAL PRIVILEGES: Name Effective from

Initial Reviewed to

Acknowledgment of Practitioner I have requested only those privileges for which my education, training, current experience and demonstrated performance I am qualified to perform and for which I wish to exercise at Jireh Counseling and Consulting Services, Inc. (JCCS), and; I understand that in exercising and clinical privileges granted, I am constrained by any Agency and Clinical Staff policies and rules applicable generally and applicable to the particular situation. Signature & credentials

Date

Name & credentials ****Agency Use Only**** Conditions/Modifications The requested clinical privelges have been approved by the Board of Directors with the following conditions, or modifications and the explanation for same. Privileges Conditions/Modifications

Explanation:

Acknowledgement: The above reflects the final action taken by the Board of Directors of Jireh Counseling and Consulting Services, Inc. Program Director

BF802- Clinical Privileges

Date

Est. Mar 2008