DA Form 5440-11: Psychology Clinical Privileges Guide

DA Form 5440-11: Psychology Clinical Privileges Guide – Military psychologists and healthcare professionals in the U.S. Army rely on standardized processes to ensure high-quality patient care. DA Form 5440-11, titled Delineation of Clinical Privileges – Clinical Psychology, serves as the official document for requesting, reviewing, and granting specific clinical privileges to psychology practitioners.

This form falls under AR 40-68, Clinical Quality Management, which governs credentialing and privileging across Army Medical Department (AMEDD) facilities.

What Is DA Form 5440-11?

DA Form 5440-11 (dated February 2004) outlines the scope of practice for clinical and counseling psychologists working in Army medical settings. It allows providers to request privileges based on their education, training, licensure, and demonstrated competence.

Key purposes include:

  • Documenting qualifications for psychological services.
  • Defining specific areas such as assessment, therapy, consultation, and specialized interventions.
  • Ensuring patient safety through supervised, competency-based privileging.
  • Supporting credentialing decisions by supervisors and credentials committees.

The form is available for official download from the U.S. Army Publications site: DA Form 5440-11 PDF.

Who Uses DA Form 5440-11?

  • Active Duty, Reserve, and National Guard clinical/counseling psychologists.
  • Civilian psychologists employed by the Army.
  • Psychology interns or post-doctoral trainees seeking supervised privileges.
  • Facility commanders, service chiefs, and credentials committees who approve privileges.

Structure of the Form and Privilege Categories

The form follows a clear, tiered structure aligned with AR 40-68 requirements.

Section I: Clinical Privileges

Providers use standardized codes to request privileges:

  • 1 — Fully competent
  • 2 — Modification requested
  • 3 — Supervision requested
  • 4 — Not requested (lack of expertise)
  • 5 — Not requested (facility/mission reasons)

Supervisors use similar codes for approval recommendations.

Privilege Categories (Progressive Levels):

  • Category I: Pre-doctoral intern level (completed internship but not yet Ph.D./Psy.D.). Works under direct supervision of a licensed psychologist. Assists with services per DA Pam 611-21 requirements.
  • Category II: Licensed Ph.D./Psy.D. holder. Provides full range of services, participates in research/teaching, and receives licensure-qualifying supervision if needed.
  • Category III: Licensed with high-level skills in assessment, intervention, and administration. May supervise lower categories.
  • Category IV: Board-certified (ABPP) with highest-level expertise. Eligible for senior supervisory and administrative roles.

Specific Privileges Requested

The form breaks privileges into detailed sections:

  • Psychological Assessment and Diagnosis: Child, Adult, Forensic, Neuropsychological, Substance Abuse.
  • Outpatient Therapy Services: Individual, Group, Marital, Family, Child, Adolescent, Geriatric, Crisis Intervention, Sexual Dysfunction, Substance Abuse, Sexual Offender.
  • Health Psychology Services: Clinical hypnosis, Biofeedback, Psychological interventions in medical settings.
  • Inpatient Psychological Services: Similar to health psychology plus assistance with inpatient management of mental disorders.
  • Consultation: Command, Command-directed evaluations, Community organization, Medical/surgical.
  • Other Specified Services: Disaster relief, Personnel assessment/selection, SERE psychology (with additional DoD requirements), Aeromedical psychology, School psychology, Combat psychology, Behavioral research.

Note: SERE (Survival, Evasion, Resistance, Escape) psychology requires separate Joint Personnel Recovery Agency credentialing.

How to Complete DA Form 5440-11? (Step-by-Step)

  1. Provider Information — Fill in name, rank/grade, and facility.
  2. Review Instructions — Understand provider and supervisor codes.
  3. Request Privileges — Code each category and specific privilege. Line through and initial non-applicable items.
  4. Sign Section I — Provider certifies the request.
  5. Supervisor Review — Supervisor codes approvals and provides overall recommendation (Section II).
  6. Credentials Committee — Final review and approval (Section III).
  7. Submit — Forward through the chain to the approval authority (typically the commander).

Any changes to approved privileges require a new DA Form 5440-11.

Why Clinical Privileging Matters in Army Psychology?

Privileging under AR 40-68 ensures:

  • Psychologists practice only within their verified competencies.
  • Alignment with DoD standards for behavioral health care.
  • Protection for both providers and patients in high-stakes military environments (deployments, command consultations, etc.).
  • Compliance with federal requirements (e.g., 10 U.S.C. for licensure).

Military psychologists often handle unique duties like fitness-for-duty evaluations, deployment screenings, and trauma care — proper privileging supports mission readiness.

  • AR 40-68: Full Clinical Quality Management regulation.
  • DA Pam 611-21: Personnel Selection and Classification procedures.
  • Army Medical Command (MEDCOM) credentialing guidance.
  • Official Army Publishing Directorate (armypubs.army.mil) for the latest forms.

Download the Current Form Here: DA Form 5440-11

Need Help with DA Form 5440-11?

If you are an Army psychologist preparing your privilege request, consult your facility’s Credentials Office or Behavioral Health Service Chief. Local policies may supplement the form with additional competency documentation (e.g., case logs, continuing education, peer reviews).

This guide reflects official U.S. Army sources as of the latest available data. Always verify with current Army regulations and your installation’s medical command for the most up-to-date requirements.