DA Form 5440-11. Delineation of Clinical Privileges-Psychology

DA Form 5440-11 is the Delineation of Clinical Privileges-Psychology form used to establish and document the clinical privileges of psychology practitioners within the Department of the Army. This form outlines the scope of psychological procedures and responsibilities that practitioners are authorized to perform.

The form consists of sections where the psychology practitioner's information is provided, including their qualifications and requested privileges. It may also include sections for listing specific psychological procedures and detailing any restrictions or limitations.

Important fields in this form include practitioner qualifications, requested psychology privileges, and specific psychological procedures authorized. Accurate completion of this form is essential for maintaining proper psychological standards and patient care.

Application Example: A psychologist seeks clinical privileges within the Department of the Army. They use DA Form 5440-11 to outline their qualifications, requested psychology privileges, and the range of psychological procedures they are qualified to perform.

No additional documents are typically required to complete this form, as it captures all necessary information related to delineating clinical privileges for psychology practitioners.

DA Form 5440-10 is a related form that serves a similar purpose but is specific to the Delineation of Clinical Privileges-Psychiatry. DA Form 5440-10 is used for psychiatric practitioners seeking clinical privileges, outlining the scope of psychiatric procedures they are authorized to perform.