Request for Specific Privileges

Name: / Click here to enter name.

DEPARTMENT OF PSYCHOLOGY

REQUEST FOR SPECIFIC PRIVILEGES

GROUP 16

HOSPITAL CARE PRIVILEGES
1.00* / ☐ / Psychological Services for Adults
2.00 / ☐ / Psychological Services for Adolescents
3.00 / ☐ / Psychological Services for Children
4.00* / ☐ / PATIENT MANAGEMENT PRIVILEGES
4.01 / ☐ / Provide, Coordinate and Evaluate Psychological Care
4.02 / ☐ / Write and Sign Treatment Plans
4.03 / ☐ / Write Orders for Medical Consultation and Other Non-Medical Services as Needed
4.04 / ☐ / Supervise Staff and Trainees
4.05* / ☐ / Enter Consultation Notes on Charts
4.06 / ☐ / Write Orders for a Sitter/Discontinue a Sitter
4.07 / ☐ / Write Orders for Toxicology Screens
4.08 / ☐ / Write Orders for Clinical Assessments
4.09 / ☐ / Write Orders for Supportive Treatment Therapy/Discontinue Supportive Treatment Therapy
5.00* / ☐ / CLINICAL ASSESSMENT PRIVILEGES
5.01* / ☐ / Behavioral Assessment
5.02 / ☐ / Neuropsychological Examination
5.03* / ☐ / Mental Status Examination
5.04* / ☐ / Intellectual Assessment
5.05* / ☐ / Personality Assessment
5.06 / ☐ / Forensic Assessment
5.07* / ☐ / Psychoeducational Assessment
5.08* / ☐ / Vocational Assessment
5.09 / ☐ / Early Childhood Developmental Assessment
5.10 / ☐ / Other, As Appropriate, Please Explain.
Click here provide explanation.
6.00* / ☐ / CLINICAL TREATMENT PRIVILEGES
6.01* / ☐ / Individual Psychotherapy
6.02* / ☐ / Group Psychotherapy
6.03* / ☐ / Family Psychotherapy
6.04* / ☐ / Behavior Modification
6.05 / ☐ / Hypnosis
6.06 / ☐ / Biofeedback
6.07 / ☐ / Emergency Room Care/Crisis Intervention
6.08 / ☐ / Pain Management, Please Specify
6.09 / ☐ / Cognitive Rehabilitation Services
6.10 / ☐ / Other, As Appropriate, Please Explain.
Click here provide explanation.
7.00* / CONSULTING PRIVILEGES
7.01* / ☐ / Consultation Liaison to Other Services, As Needed
7.02* / ☐ / Professional Development Services Within the Facility
7.03* / ☐ / Program Planning and Evaluation

______

Signature Date

********************************************************************************************

Department:

Reviewed and recommended, as requested:_____

Reviewed and recommended, with exception:_____

Reviewed but not recommended:_____

______

Chairperson Date

Medical Staff Executive Committee:

Reviewed and recommended, as requested:_____

Reviewed and recommended, with exception:_____

Reviewed but not recommended:_____ Date______

Board of Hospital Managers:

Reviewed and approved, as recommended:_____

Reviewed and approved, with exception:_____

Reviewed but not approved:_____ Date______

Note: If privileges are denied, limited, or granted other than as requested, documentation must be provided.

* Denotes basic privilege which may be granted to a fully licensed clinical psychologist, if requested. All other privileges require documentation as to experience and/or training, according to the standards established by the department.