SOP_NUMBER: 508.04-att-1
TITLE: Request For Clinical Privileges
REFERENCE_CODE: VG10-0001
DIVISION: Mental Health Services
TOPIC_AREA: 508 Policy-MH Administration/Staff/Certification
EFFECTIVE_DATE: 2020-12-14
WORD_COUNT: 228
POWERDMS_URL: https://public.powerdms.com/GADOC/documents/265873
URL: https://gps.press/sop-data/508.04-att-1/
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
ATTACHMENTS:
1. Request For Clinical Privileges
URL: https://gps.press/sop-data/508.04-att-1/
3. Criteria for Clinical Privileges
URL: https://gps.press/sop-data/508.04-att-3/
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FULL TEXT:
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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.