Psychology

PSYCHOLOGY Privilege Form Name: __________________________________________ The minimum education, training, and experience qualifications for core privileges are as delineated in Jireh Counseling and Consulting Service Credentialing and Privileging policy. Please consult this documents to determine your eligibility to request these privileges. LEGEND: 1 – DHR Wrap Around 2 – DHR CCFA 3 – DMHDDAD Core Services 4 - DMHDDAD Intensive Family Intervention To request privileges, please place an “X” in the appropriate column 1

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CORE PRIVILEGES General Assessment: Psychological assessment and therapy with individuals experiencing emotional distress, and assessment of intellectual abilities. SPECIAL PROCEDURES Procedures which may require proof of training or experience Behavior Therapy Family Therapy Group Therapy Individual Psychotherapy Play Therapy Other specific privileges requested:

Acknowledgment of Practitioner: I understand that (a) in exercising clinical privileges granted, I am constrained by JCCS Clinical Staff policies, rules and regulations, and (b) any restriction on the clinical privileges granted to me is waived in an emergency situation and in such situation my actions are governed by the applicable section of JCCS Clinical policies. Applicant Signature: _________________________________________________

BF802.3 Psychology Privilege Form

Date: ________________

Est. Mar 2008