DA Form 5441-11. Evaluation of Clinical Privileges - Clinical Psychology

DA Form 5441-11 is utilized for the evaluation of clinical privileges within the field of Clinical Psychology. This form is a crucial tool for assessing and establishing the qualifications and requested privileges for licensed clinical psychologists involved in diagnosing and treating mental health disorders.

The form comprises sections where the clinical psychologist provides personal and professional details, including licenses, certifications, and qualifications relevant to clinical psychology practice. It necessitates outlining the requested clinical privileges, covering areas such as psychological assessments, psychotherapy, and mental health interventions.

Important fields in this form include the clinical psychologist's identification information, requested clinical privileges, and supporting documentation showcasing their expertise in clinical psychology. Accurate completion of this form is paramount to ensure that the clinical psychologist is granted privileges aligned with their proficiency in diagnosing and treating mental health disorders.

Application Example: A licensed clinical psychologist joining a military medical facility would utilize DA Form 5441-11 to request clinical privileges. By accurately completing the form and providing necessary documentation, the psychologist's proficiency in mental health assessments and therapy is evaluated, enabling the medical facility to grant appropriate privileges.

No additional documents are explicitly mentioned as required for filling this form.

Related Form: DA Form 5441-12, 5441-13, 5441-14, and 5441-15 are related forms intended for different clinical privilege evaluation processes.