DA Form 5441-34. Evaluation of Clinical Privileges - Behavioral Health Practitioner

DA Form 5441-34 serves the purpose of evaluating clinical privileges for Behavioral Health Practitioners. This form plays a critical role in assessing and establishing the qualifications and requested privileges for practitioners specializing in providing behavioral health interventions and therapy.

The form comprises sections where the behavioral health practitioner provides personal and professional details, including licenses, certifications, and qualifications specific to behavioral health practice. It requires outlining the requested clinical privileges, encompassing areas such as individual and group therapy, mental health assessments, and crisis intervention.

Key fields in this form include the practitioner's identification information, requested clinical privileges, and supporting documentation showcasing their expertise in behavioral health practice. Accurate completion of this form is crucial to ensure that the practitioner is granted privileges aligned with their proficiency in delivering behavioral health interventions.

Application Example: A licensed clinical psychologist joining a military medical facility would utilize DA Form 5441-34 to request clinical privileges. By accurately completing the form and providing necessary documentation, the practitioner's proficiency in individual and group 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 5441-32, 5441-33, 5441-35, and 5441-36 are related forms intended for different clinical privilege evaluation processes.