Clinical Social Work

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

My training and experience is in the psychosocial assessment and treatment of
individuals, couples, family and groups experiencing emotional distress in the below
areas:
1 2 3 4 CORE PRIVILEGES
Adults
Adolescents
Children

1 2 3 4 SPECIAL PROCEDURES - Procedures which may require proof of training or

experience
Behavior Therapy
Couples Therapy
Family Therapy
Group Therapy
Individual Psychotherapy
Stress Management
Other:

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: __________

BF802.1 Clinical Social Work Est. Mar 2008