University of California Student Health and Counseling Services

UNIVERSITY OF CALIFORNIA STUDENT HEALTH AND COUNSELING SERVICES

PSYCHOLOGY

PRIVILEGE DELINEATION FORM

This privilege form describes the qualifications related to competency to exercise the defined clinical privileges that may be requested by a qualified practitioner based on the training and experience required. Privileges granted may only be exercised at the site(s) and setting(s) that have the appropriate equipment, staff, and other support required to provide the services defined in this document. The applicant must also adhere to additional organizational, regulatory, or accrediting requirements that this facility is obligated to meet.

NAME:

(Please Print)

Requested / Approved / EMERGENCY / DISASTER Privileges
(NOT TO EXCEED 30 DAYS; GRANTED ONLY WHEN IMMEDIATE NEEDS OF PATIENTS CANNOT BE MET) / Required Criteria
 /  / CORE Privileges: Psychiatric evaluation and treatment:
Conduct extensive history and examination on culturally diverse patients
Conduct comprehensive diagnostic mental status exam and relevant screening neurological examination
Develop and document an appropriate DSM multi-axial differential diagnosis and integrative case formulation including biological, psychological and sociocultural domains
Conduct necessary evaluations including appropriate laboratory, imaging, medical and psychological examinations
Psychiatric risk assessment: Comprehensive assessment of a patient’s potential for self-harm or harm to others, as well as the ability to implement prevention methods against self-harm and harm to others in an effort to minimize risk
Psychiatric treatment planning:
Treatment planning that addresses biological, psychological and sociocultural domains; Determine if a patient’s symptoms are due to a psychiatric disorder, or are of another origin, e.g., the result of a systemic or neurological disease; Evaluate the indication for, relevance of and application of light therapy, electroconvulsive therapy, trans-cranial magnetic stimulation and vagal nerve stimulation
Psychiatric psychotherapy: Conduct a range of individual, group and family therapies using standard, accepted models and to integrate these psychotherapies in multi-modal treatment, including biological and sociocultural interventions; Psychopharmacology: Initiate titrate and monitor appropriate psychotropic medications
Psychiatric consultation: Consult with physicians in other fields regarding neuropsychiatric, mental, behavioral, and emotional disorders; Consult with psychologists, social workers and other mental health care providers regarding neuropsychiatric, mental, behavioral and emotional disorders;
Chemical dependency intervention and therapy: Assess for signs and symptoms of dependency, tolerance and withdrawal; Initiate medical and psychiatric treatment as necessary; Refer to inpatient and outpatient settings as needed.
Psychiatric referral: Refer patients when appropriate for inpatient treatment, emergency room evaluation, intensive outpatient treatment, or long-term outpatient treatments; Psychiatric supervision/training: Provide supervision and training as needed for psychiatry, internal medicine, family medicine, neurology, pediatric residents. / Successful completion of ACGME or AOA accredited residency/fellowship in Psychiatry or foreign equivalent training; AND
Active, valid California medical license

I certify that I have had the necessary training and experience to perform the procedures that I have requested. The burden of producing information deemed adequate by the organization for a proper evaluation of current competence, current clinical activity and other qualifications and for resolving any doubts related to qualifications for the requested privileges is mine. I have reviewed all the criteria that pertain to those privileges that I am requesting and I certify that I meet those criteria. In exercising the privileges granted to me, I agree to strictly abide by the facility’s Credentialing Policies and Procedures.

Applicant: (Signature & Print) / Date

RECOMMENDATIONS/APPROVAL

I have reviewed the applicant’s credentials, experience, training, health status, current competence and peer recommendations relative to this request for privileges. The following recommendations are made:

CS or Med Director______Date ___/____/____ APPROVED DENIED DEFERRED

Executive Director ______Date ___/____/____ APPROVED DENIED DEFERRED

Privileges Effective: From ___/____/____ to ___/____/____ (not to exceed 30 days)

(The Executive Director, Medical Director or CS Director or designees may grant Disaster Privileges.)

12/2017