SOP 508.04-att-1: Request For Clinical Privileges

Division:
Mental Health Services
Effective Date:
December 14, 2020
Reference Code:
VG10-0001
Topic Area:
508 Policy-MH Administration/Staff/Certification
PowerDMS:
View on PowerDMS
Length:
228 words

Summary

This form is used by the Georgia Department of Corrections Mental Health Services to document and approve clinical privileges for mental health staff members. It allows supervisors to review and approve or disapprove staff requests for authorization to perform various clinical services including counseling, therapy, evaluations, and psychological testing. The form must be completed annually and maintained in the staff member's credentialing file.

Key Topics

  • clinical privileges
  • mental health staff certification
  • counseling authorization
  • therapy privileges
  • psychological evaluation
  • mental health services
  • staff credentialing
  • privilege approval
  • clinical supervision
  • mental health assessment

Full Text

SOP 508.04
Attachment 1

12/14/20

GEORGIA DEPARTMENT OF CORRECTIONS - MENTAL HEALTH SERVICES
REQUEST FOR CLINICAL PRIVILEGES

Applicant's Name:_________________________________ Title:_______________________________
Date:________________________
Your request for clinical privileges in the areas you requested have been carefully considered. Based upon your
qualifications and experience the privileges listed below have been either approved or disapproved.

|Col1|Requested|Approved|Col4|Disapproved|
|---|---|---|---|---|
|
1. Counseling||
With
Supervision|
Without
Supervision||
|A. Supportive Counseling (individual)|||||
|B. Psycho educational training (group)|||||
|C. Case Management|||||
|D. Life Skills Training|||||
||||||
|
II. Therapy|
II. Therapy|
II. Therapy|
II. Therapy|
II. Therapy|
|A. Individual Therapy|||||
|B. Group Therapy|||||
|C. Sexual Abuse Therapy|||||
|D. Crisis Intervention|||||
||||||
|
III. Evaluations|
III. Evaluations|
III. Evaluations|
III. Evaluations|
III. Evaluations|
|A. Mental Health Reception Screen|||||
|B. Mental Health Service Screen|||||
|C. On-Call Crisis Triage|||||
|D. Sexual Abuse Evaluation|||||
|E. Disciplinary Evaluation|||||
|F. Administrative Segregation Evaluation|||||
|G. Parole Psychological Evaluation|||||
||||||
|
IV. Psychological Testing (Administration & Scoring)|
IV. Psychological Testing (Administration & Scoring)|
IV. Psychological Testing (Administration & Scoring)|
IV. Psychological Testing (Administration & Scoring)|
IV. Psychological Testing (Administration & Scoring)|
|A. Intelligence|||||
|B. Objective Personality|||||
|C. Projective Personality|||||
|D. Neuropsychological|||||

___________________________________________________ _________________________
Applicant's Signature Date

________________________________________________________ ____________________________
Clinical Supervisor's/Consultant's Signature/Title Date

Form no. M10-01-01 Page 1 of 1

Retention Schedule: Upon completion, the original of this form shall be placed in the applicant’s/staff member’s credentialing/privileging file and
a copy will go to the applicant/staff member. The form will be completed annually.

Attachments (2)

  1. Request For Clinical Privileges (228 words)
  2. Criteria for Clinical Privileges (1,007 words)
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