Health facility peer review reporting form - Board of Behavioral 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the 'Name of Reporting Entity' and 'Telephone Number' in the designated fields. This information identifies who is submitting the report.
3. Fill in the 'Address of Reporting Entity' to provide a complete contact address for follow-up.
4. Input the 'Name of Licentiate' and their corresponding 'License or Registration Type and Number'. Select from options like Clinical Social Worker, Marriage and Family Therapist, or Professional Clinical Counselor.
5. Document the 'Date(s) of Action(s) and Duration'. If more space is needed, attach additional sheets as necessary.
6. Mark all applicable 'Type(s) of Action(s)' that occurred, ensuring you check any relevant boxes for actions taken against staff privileges or membership.
7. In the section for specific restrictions imposed, detail any restrictions on staff privileges or employment if applicable.
8. Provide a thorough 'DESCRIPTION OF ACTION', attaching additional sheets if required to explain circumstances surrounding the disciplinary action.
9. Finally, ensure that signatures are obtained from both the Chief Executive Officer/Medical Director/Administrator and Chief of Medical Staff where applicable, along with their printed names and dates.

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