DEPARTMENT OF PSYCHIATRY
DELINEATION OF PRIVILEGES FOR CLINICAL PSYCHOLOGIST
Name:________________________________________ Date:_____________________
Applicant: Check off the “Requested” box for each privilege requested. Applicants may be
required to provide information deemed necessary for a complete evaluation of current
competence, current clinical activity, and other qualifications, and for resolving any doubts
related to qualifications for requested privileges.
QUALIFICATIONS FOR PSYCHOLOGIST
To be eligible to apply for clinical privileges as a psychologist, the applicant must meet
the following criteria:
Current active certification and license to practice issued by the New York State Department of
Education.
Possess an earned doctorate degree (PhD or PsyD) in psychology from an American
Psychological Association accredited program or the substantial equivalent thereof as
determined by NYSED and have completed at least two years of clinical experience in an
organized healthcare setting supervised by a licensed psychologist, one year of which must
have been post-doctoral, and an internship endorsed by the American Psychological
Association or the substantial equivalent thereof as determined by NYSED.
PSYCHOLOGIST CORE PRIVILEGES
Requested Diagnose and provide treatment and consultation to children, adolescent, and
adult patients who suffer from mental, behavioral, or emotional disorders. Assess, stabilize, and
determine the disposition of patients with emergent conditions consistent with medical staff
policy regarding emergency and consultative call services. The core privileges in this specialty
include the procedures on the attached procedure list and such other procedures, including
supervision of patient care that are extensions of the same techniques and skills.
CORE PROCEDURE LIST
____________________________________________________________________________
This list is a sampling of procedures included in the core. This is not intended to be an allencompassing list but rather reflective of the categories/types of procedures included in the
core.
To the applicant: If you wish to exclude any procedures, please strike through those
procedures you do not wish to request, then initial and date.
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Family assessment/therapy
Group therapy
Marital or couples therapy
Psychological assessment
Psychotherapy
Hypnotherapy
Behavioral Modification therapy
Biofeedback therapy
Neuropsychological testing
Other:
 Evaluate, counsel and provide individual, group, and family psychotherapy for the prevention,
diagnosis, and treatment of mental, emotional, and behavioral disorders.
 Administer and interpret tests of cognitive abilities and aptitudes, clinical syndromes,
psychological status, personality variables, emotions, and motivation.
 Evaluate and develop treatment plans and address issues of addictions, cognitive impairments, and
neuropsychological disorders.
 Provide recommendations for education and vocational planning.
 Provide diagnostic considerations and recommendation to treat a variety of psychological issues
affecting adult through geriatric.
 Communicate with family and providers in an effort to assure that physical challenges related to
mental health are properly treated or monitored.
 Assist with identifying the underlying causes of certain behavioral changes and refer for further in
or out patient treatment as needed.
 Address issues of depression, anxiety, psychosocial changes and grief management, including
mental health issues related to pain and illness.
ACKNOWLEDGEMENT OF PRACTITIONER
AGE RESTRICTION:
_____ No restriction
_____ I only treat patients over / under (circle one) the age of ______.
I have requested only those clinical privileges for which by education, training, current
experience, and demonstrated performance I am qualified to perform and for which I wish to
exercise at HealthAlliance facilities and I understand that:
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a. In exercising any clinical privileges granted and in carrying out the responsibilities
assigned to me, I am constrained by hospital and medical staff policies and rules
applicable generally and any applicable to the particular situation.
b. Any restriction on the clinical privileges granted to me is waived in an emergency
situation and in such situation my actions are governed by the applicable section of the
policies governing privileged allied health professionals.
Signed___________________________________________________ Date_______________
Signature of
Department Chair for Psychiatry _______________________________________Date ____________________
Broadway and Mary’s Avenue Campuses
Addendum
1. Are you currently actively practicing as a psychologist? Yes ___ No ___
2. Approximate number of hours weekly of treatment, evaluation, or consultation provided: _______
3. What are your areas of specialization, if any: ______________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
4. Have you encountered any significant problems or complaints within the past two
years? Yes ___ No ___ If so, please explain: ________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
The undersigned hereby affirms under the penalties of perjury as follows: that he/she
is the respondent applying to a HealthAlliance Facility for privileges; that he/she has
read the above questions; and that the answers given to the same are complete, true
and accurate to his/her own knowledge and belief.
___________________________________________________ _________________
Signature of Applicant Date
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