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 document 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 2 3 4 CORE PROCEDURES Admission of consumers Consultation, inpatient and outpatient assessment, diagnosis, and treatment of patients presenting with mental illness. These privileges include psychotherapy, group therapy, family therapy, behavior modification, pharmacotherapy, neuroendocrine challenge test, chemical dependency treatment, physical examination, diagnosis and treatment of routine medical disorders, general neurological evaluation, and the ordering of laboratory and radiological procedures. 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: _________________________________________________ Date: _________________

BF802.2 Psychiatry Privilege Form

Est. Mar 2008

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