DA Form 5440-35: Psychological Associate Privileges Guide – Are you a master’s-level psychological associate, Licensed Professional Counselor (LPC), or similar behavioral health provider seeking clinical privileges in a U.S. Army medical treatment facility (MTF)? DA Form 5440-35 is the official document used to request, review, and grant these privileges. This form ensures that only qualified providers deliver safe, supervised psychological services under Army standards.
What Is DA Form 5440-35?
DA Form 5440-35, titled Delineation of Clinical Privileges – Psychological Associate, is a two-page U.S. Department of the Army form released in February 2004. It falls under AR 40-68 (Clinical Quality Management), with the Office of The Surgeon General (OTSG) as the proponent agency.
The form documents a provider’s qualifications and requested scope of practice in psychological assessment and related services. It categorizes privileges by level of supervision and experience, then lists specific procedures (primarily psychological testing and evaluation). Once approved, any changes require a new submission.
Download the official form here: https://armypubs.army.mil/pub/eforms/DR_a/pdf/A5440_35.pdf
Who Uses DA Form 5440-35?
This form targets:
- Master’s-level psychological associates
- Licensed Professional Counselors (LPC) or equivalent state licenses
- Other qualified master’s-level psychology providers working in Army behavioral health settings
It applies to both military and civilian providers in Army MTFs who perform psychological services under the supervision of a licensed psychologist.
Key Sections of the Form
Section I – Clinical Privileges (Provider completes this)
Providers use standardized codes:
| Provider Code | Meaning |
|---|---|
| 1 | Fully competent |
| 2 | Modification requested |
| 3 | Supervision requested |
| 4 | Not requested (lack of expertise) |
| 5 | Not requested (facility/mission) |
Privilege Categories:
- Category I: Entry-level. Direct supervision by a licensed psychologist. For unlicensed or new master’s graduates (full supervision in first year). Requires accredited master’s degree + minimum supervised practicum.
- Category II: General supervision. Requires state licensure (e.g., psychological associate or LPC) + 2+ years post-licensure experience for reduced oversight.
- Category III: Advanced. Allows broader assessment services and supervision of lower categories. Requires post-master’s specialty degree, comprehensive exam, and licensure. Supervision limited to high-risk or out-of-scope cases for experienced providers.
Specific Privileges – Psychological Testing (examples):
- Conduct intake interviews and psychosocial assessments
- Mental status evaluation and behavioral observations
- Recommend and administer psychological tests
- Score tests and integrate data
- Provisional diagnosis using DSM
- Prepare evaluation reports (under general supervision)
- Provide feedback to patients
Sections II & III: Supervisor and Credentials Committee recommendations and approvals.
How to Complete DA Form 5440-35? (Step-by-Step)
- Enter personal details (Name, Rank/Grade, Facility).
- Review each category and procedure.
- Mark the appropriate code in the REQUESTED column.
- Sign and date Section I.
- Supervisor reviews and marks APPROVED column, then provides overall recommendation.
- Credentials Committee reviews and recommends to the commander (final approval authority).
Tip: Attach justification for any modifications. Keep copies for your credentials file.
Supervision Requirements (Per AR 40-68)
- New licensees: Full supervision in the first year.
- Experienced (2+ years): General supervision based on competence.
- Specialty-trained: Limited supervision for complex cases only.
This structure protects patients while allowing experienced associates to practice effectively within Army behavioral health programs.
Why Proper Privileging Matters?
Clinical privileging under AR 40-68 upholds high standards of care, ensures compliance with state licensing where applicable, and supports mission readiness. Accurate completion of DA Form 5440-35 helps integrate qualified psychological associates into multidisciplinary teams providing mental health services to service members and families.
Related Forms
- DA Form 5440-11 (Clinical Psychology – for doctoral-level psychologists)
- DA Form 5440-34 (Behavioral Health Practitioner)
- DA Form 5440 series for other specialties
For the latest guidance, visit the Army Publishing Directorate or your local MTF Credentials Office.