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 2 3 4 CORE PRIVILEGES
General Assessment: Psychological assessment and therapy with individuals
experiencing emotional distress, and assessment of intellectual abilities.
SPECIAL PROCEDURES
1 2 3 4 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: _________________________________________________ Date: ________________

BF802.3 Psychology Privilege Form Est. Mar 2008