EDWIN FAIR COMMUNITY MENTAL HEALTH CENTER

CLINICAL PRIVILEGING FORM

______

Date

NAME / DEGREE / AREA OF DEGREE

Forms/Clinical/ClinicalPrivilegingForm.doc Rev: 8/19/11 1

LBHP AUTHORIZATION

(LICENSED BEHAVIORAL HEALTH PROFESSIONAL)

MD Board Certified License # ______
Master’s Degree in Mental Health Field and Licensed License #______
Receiving supervision for licensing in (Requires supervisor’s contract and/or letter from Licensing Board for personnel file):
Psychology
Social Work (clinical specialty only)
Professional Counselor
Marriage & Family therapy
Behavioral Practitioner
Advanced Practice Nurse: certified in a psychiatric mental health specialty /
RN with Board Certification
License # ______
AODTP or Licensed AODTP
License # ______

PSRS (PSYCHIATRIC-SOCIAL REHAB. SPEC.)

Bachelor’s
Licensed R.N. License # ______
Master’s Degree in MH field
AODTP CADC Certification # ______

CERTIFIED BEHAV. HEALTH CASE MGR.

LBHP
BHRS and/or DMH Case Mgmt. Cert.:
Circle one of the following: I - II - III
Certificate # ______
Effective Date of Provisional Certificate: ______
LICENSED PRACTICAL NURSE:
License #______

TRAINING / OTHER CERTIFICATION

PACT Training – Date:
ASI Training – Date:
ASAM Training – Date:
PSR Training – Date:
RECOVERY SUPPORT SPEC. (RSS) Training – Date:
Effective Date of Certification
for RSS:

Based upon review of the training, this person is privileged to perform the following:

Evaluation / YES / NO
Assessment (101)-MHP Only
Assessment (105)-BHRS and up
Substance Abuse Assessment
Treatment Plan Development
Referral (105) – BHRS and up
Clinical Testing – Type: ______/ Date:
Clinical Testing – Type: ______/ Date:
Crisis Intervention Services / YES / NO
Emergency On-Call System
North Emergency Team must have hospital privileges for Ponca City Med Ctr.
Crisis Intervention (Licensed staff only)
On-Call Specialized Training
Completed on - / Date:
Method / YES / NO
Individual Psychotherapy (LBHP only)
Group Psychotherapy (LBHP only)
Family Psychotherapy (LBHP only)
Individual P/S Rehab
Group P/S Rehab
Individual Rehab P/S Skills Dev.
Group Rehab P/S Skills Dev.
Case Management
Medication Training and Support (RN)
Pharmacological Mgmt. (MD)
Outreach

______

Staff Signature

______

Program Coordinator

______

Clinical Director

______

Executive Director

______

Compliance Coordinator

Forms/Clinical/ClinicalPrivilegingForm.doc Rev: 8/26/08 2

EDWIN FAIR COMMUNITY MENTAL HEALTH CENTER, INC.

CLINICAL PRIVILEGING FORM FOR SUBSTANCE ABUSE SERVICES

______

Date

______

Name Degree Area of Degree

Any outpatient services provided under the Department of Mental Health contract for Substance Abuse Services (Contract Source 02) shall be provided by professional treatment staff.

Professional treatment staff are knowledgeable regarding biopsychosocial dimensions of substance abuse, counseling theory and techniques and possess one of the following:

1. A current license as a physician in the State of Oklahoma; or

2. A doctoral degree in psychology; or

3. LADC – licensed in the State of Oklahoma as a Drug and Alcohol Treatment Provider; or

Staff not meeting one of the above requirements shall have a current certification as a CADC or be working toward CADC certification; and shall have:

4. A master’s degree in counseling, psychology, social work, an addiction related field; or

5. A minimum of one year of supervised experience in an addiction treatment setting and a bachelor’s degree in counseling, psychology, social work, or a bachelor’s degree in a related field and at least 12 hours in counseling coursework; or

6. A current license as a registered nurse in the State of Oklahoma, plus a minimum of two years of supervised experience in an addiction treatment setting; or

7. A current certification as a certified alcohol counselor.

PROFESSIONAL TREATMENT STAFF ARE PRIVILEGED TO PERFORM THE FOLLOWING:

101 Evaluation and Assessment 105 Referral

120 Crisis Intervention (face-to-face) 121 Crisis Intervention (telephone)

130 Individual Counseling 131 Group Counseling

132 Family/Marital Counseling 224 Family Support Services

225 Case Management 400 Treatment Planning

551 Community Outreach 218 Diagnosis/Problem related Education (Individual)

219 Diagnosis/Problem Related Education (Group)

ASI Training completed on ______

ASAM PPC-2R Training completed on ______

______

Staff Signature Program Coordinator

______

Executive Director Clinical Director

Forms/Clinical/ClinicalPrivilegingForm.doc Rev: 8/26/08 2