Mental Health (Psychology) Treatment Plan

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 (*).
Client details (The client has a current claim with the TAC and is seeking psychological treatment for their transport accident injuries.)
Date of birth *
Date of accident *
Referral

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

Date of referral *
Current presenting problems

In order of priority, from most important to least important, list the 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
Current and past diagnoses

(in accordance with DSM 5)

First Diagnoses
Date of diagnosis *
Are diagnostic criteria currently met? *
Related to transport accident? *
Second Diagnoses
Date of diagnosis
Are diagnostic criteria currently met?
Related to transport accident?
add 3rd diagnosis
Third Diagnoses
Date of diagnosis
Are diagnostic criteria currently met?
Related to transport accident?
add 4th diagnosis
Fourth Diagnoses
Date of diagnosis
Are diagnostic criteria currently met?
Related to transport accident?
Did you treat this client prior to the transport accident? *
Pre accident status

List the person’s pre accident status, including highest level of education achieved, employment at the time of the transport accident, other significant previous employment, social status 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, legal
Progress review
Date of first session with yourself: *
1st Goal
(Functional gains)
(eg. DASS, PCL, PSEQ)
2nd Goal
(Functional gains)
(eg. DASS, PCL, PSEQ)
add 3rd goal
3rd Goal
(Functional gains)
(eg. DASS, PCL, PSEQ)
add 4th goal
4th Goal
(Functional gains)
(eg. DASS, PCL, PSEQ)
Client Empowerment to manage their condition

(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
(refer to Principle 4 of the Clinical Framework)
(refer to Principle 5 of the Clinical Framework)
(Eg. DASS, PCL, PSEQ) (Refer to Principle 1 of the Clinical Framework)
(refer to Principle 1 of the Clinical Framework)
Estimated date of achievement or review *
Practical goal 2
(refer to Principle 4 of the Clinical Framework)
(refer to Principle 5 of the Clinical Framework)
(Eg. DASS, PCL, PSEQ) (Refer to Principle 1 of the Clinical Framework)
(refer to Principle 1 of the Clinical Framework)
Estimated date of achievement or review *
add 3rd practical goal
Practical goal 3
(refer to Principle 4 of the Clinical Framework)
(refer to Principle 5 of the Clinical Framework)
(Eg. DASS, PCL, PSEQ) (Refer to Principle 1 of the Clinical Framework)
(refer to Principle 1 of the Clinical Framework)
Estimated date of achievement or review
add 4th practical goal
Practical goal 4
(refer to Principle 4 of the Clinical Framework)
(refer to Principle 5 of the Clinical Framework)
(Eg. DASS, PCL, PSEQ) (Refer to Principle 1 of the Clinical Framework)
(refer to Principle 1 of the Clinical Framework)
Estimated date of achievement or review
Group treatment request

If the treatment plan includes group treatment for this client, please complete this section. (The goals of group treatment should be outlined with the agreed future treatment plan above.)

Treatment requested for approval

Duration of this plan

Commencement date of the requested services *
Completion date of the requested services *
Commencement date of the requested group services
Completion date of the requested group services
Client’s natural supports
(e.g. family and community relationships)
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
Multidisciplinary coordination and medications

(Refer to Principle 2 of the Clinical Framework)
List other providers of treatment to this person, including professional and other carers and their interventions including psychotropic medication prescribed.

Have you liaised with others in relation to multidisciplinary coordination and medications *
First multidisciplinary provider / treatments
(eg name, location if known)
eg. physiotherapy, drug name
Date of your last contact with provider
Second multidisciplinary provider / treatment
(eg name, location if known)
(eg. physiotherapy, drug name)
Date of your last contact with provider
List another provider/treatment
Third multidisciplinary provider / treatement
(eg name, location if known)
(eg. physiotherapy, drug name)
Date of your last contact with provider
Vocational needs
Other comments and issues

Please note any other issues and needs for this person. This may include occupational, physical or social/family needs beyond those already expressed within this document.

Acknowledgement

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

I have discussed this treatment plan with my patient 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 patient’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.