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  5. Mental health (Neuropsychology) Treatment plan

Mental Health (Neuropsychology) Treatment Plan

Complete this form:

  1. for new TAC clients who require more than 6 pre-approved services, or
  2. when requested by the TAC.

The client must have a current claim with the TAC and be seeking neuropsychological treatment for their transport accident injuries. For ongoing treatment to be approved, it must be clinically justified by satisfying the five principles of the Clinical Framework for the Delivery of Health Services

Required fields are marked with an asterisk (*).
TAC client details
Date of birth (dd/mm/yyyy) *
Date of accident (dd/mm/yyyy) *
Referral

Who was the medical practitioner that referred this client to you?

Date of referral (dd/mm/yyyy) *
Current presenting problems

List the accident-related problems that are currently preventing this client returning to valued roles in their family, social and productive work or related activities. For each problem give the key indicators, sign and symptoms associated with the problem.

add 3rd
add 4th
add 5th
Head injury
Did the person suffer a head injury *

E.g. Glasgow coma scale (GCS), Post-traumatic amnesia (PTA), Loss of consciousness (LOC), Length of LOC, Radiological findings.

Current functioning

On the basis of your assessment, if repeated since the last plan, report information on current status and effects of brain injury on function in the following areas. Please indicate if those problems are directly related to the transport accident.

Axis 1. Cognitive (e.g. memory, executive dysfunction)
Functional problem? *
Related to transport accident? *
Axis 2. Behavioural (e.g. verbal and physical aggression)
Functional problem? *
Related to transport accident?
Axis 3. Emotional (e.g. anxiety, mood disorder)
Functional problem? *
Related to transport accident? *
Pre-accident status

List the person’s pre-accident status, including education achieved, employment, social situation and living arrangements. List pre-accident issues including medical conditions.

(medical, cognitive, behavioural, emotional, social)

Identify risk factors for recovery

Risk factors may be physical, mental, social, cultural, occupational or legal. These may be current events, challenges or stressors and may be related or unrelated to the transport accident.

Progress review
Date of first session with yourself: (dd/mm/yyyy) *

We'll ask you to provide details about goal progress if the client has had 3 or more sessions with you.

Goals

(please make reference to functional gains)

Add 2nd goal
2nd Goal

(please make reference to functional gains)

add 3rd goal
3rd Goal

(please make reference to functional gains)

add 4th goal
4th Goal

(please make reference to functional gains)

Relevant tasks and Behaviour Support Plan

(e.g. staff/care support training, development of materials, Behaviour Support Plan)

Is there a Behaviour Support Plan in place?
Are there restrictive practices involved?

Please see our Restrictive practice policy for more information

Has the Behaviour Support Plan been submitted to the Victorian Senior Practitioner?
Has the Behaviour Support Plan been submitted to the TAC?
Client empowerment to manage their condition and support independence

Refer to Principle 3 of the Clinical Framework
Agreed future treatment plan

Includes individual and group treatment.

What practical goals have been agreed with the client? How will these goals be achieved, by what date, and using what progress measures?

Practical goal 1

Refer to Principle 4 of the Clinical Framework

Example: Driving in wet conditions with reduced anxiety by November.

Refer to Principle 5 of the Clinical Framework

Example: In-vivo and imaginal exposure (TF-CBT).

Refer to Principle 1 of the Clinical Framework.

For example, DASS 21, PCL 5, OBS, GAS goals, number of social activities per week. See tac.vic.gov.au/outcomes.
Practical goal 2

Refer to Principle 4 of the Clinical Framework

Example: Driving in wet conditions with reduced anxiety by November.

Refer to Principle 5 of the Clinical Framework

Example: In-vivo and imaginal exposure (TF-CBT).

Refer to Principle 1 of the Clinical Framework.

For example, DASS 21, PCL 5, OBS, GAS goals, number of social activities per week. See tac.vic.gov.au/outcomes.
add 3rd practical goal
Practical goal 3

Refer to Principle 4 of the Clinical Framework

Example: Driving in wet conditions with reduced anxiety by November.

Refer to Principle 5 of the Clinical Framework

Example: In-vivo and imaginal exposure (TF-CBT).

Refer to Principle 1 of the Clinical Framework.

For example, DASS 21, PCL 5, OBS, GAS goals, number of social activities per week. See tac.vic.gov.au/outcomes.
add 4th practical goal
Practical goal 4

Refer to Principle 4 of the Clinical Framework

Example: Driving in wet conditions with reduced anxiety by November.

Refer to Principle 5 of the Clinical Framework

Example: In-vivo and imaginal exposure (TF-CBT).

Refer to Principle 1 of the Clinical Framework.

For example, DASS 21, PCL 5, OBS, GAS goals, number of social activities per week. See tac.vic.gov.au/outcomes.
Treatment requested for approval
Commencement date of requested services (dd/mm/yyyy) *
Completion date of requested services (dd/mm/yyyy) *
Commencement date of requested services (dd/mm/yyyy)
Completion date of requested services (dd/mm/yyyy)

Specify other activities that will be included in the treatment (e.g. training, care team meetings).

Identify travel hours required. Please outline the reasons for travel and which alternatives have been explored (e.g. referral to a local provider, telehealth).

Client’s natural supports
Expected transition to self management

In accordance with Principle 3 of the Clinical Framework, treatment must focus on empowering the client to manage their injury.

Date of expected discharge of client to self-management (dd/mm/yyyy)
Multidisciplinary coordination

Identify other providers of treatment for this person. Multidisciplinary collaboration is known to improve client outcomes. Refer to Principle 2 of the Clinical Framework.

First multidisciplinary provider
Has collaboration taken place?
Written, verbal or both?
Would you like the provider's details so you can contact them?
Add another provider?
Second multidisciplinary provider
Has collaboration taken place?
Written, verbal or both?
Would you like the provider's details so you can contact them?
Add another provider?
Third multidisciplinary provider
Has collaboration taken place?
Written, verbal or both?
Would you like the provider's details so you can contact them?
Vocational/study needs
Has the client returned to pre transport accident employment or study?
Other comments and issues

This may include occupational, physical or social/family needs or safeguarding issues beyond those already expressed within this document.

Restorative Justice Program Referral
Would this client benefit from a Restorative Justice Program?

See tac.vic.gov.au/restorative-justice for details. If ‘yes’ is selected, the TAC Restorative Justice Coordinator will reach out to the client for further assessment and potential engagement with the Restorative Justice Program.

Acknowledgement

This plan should be agreed to by the provider and the client to whom they are providing treatment.

I have discussed this treatment plan with my client and I agree to discuss this plan with members of the TAC Clinical Panel as required. I understand that I can only bill the TAC for treatment that is directly related to my client’s transport accident. *
Provider details

Your privacy

The TAC will retain the information provided and may use or disclose it to make further enquiries to assist in the ongoing management of the claim or any claim for common law damages. The TAC may also be required by law to disclose this information.

Without this information, the TAC may be unable to determine entitlements or assess whether the treatment is reasonable and may not be able to approve further benefits and treatment.

If you require further information about our privacy policy, please call the TAC on 1300 654 329 or visit our privacy policy .