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  5. Mental Health (Psychology) Treatment Plan

Mental Health (Psychology) Treatment Plan

Complete this form:

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

The client must have a current claim with the TAC and be seeking psychological treatment for their transport accident injuries. For ongoing treatment to be approved, it must be clinically justified by satisfying the 5 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 currently preventing this client from 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

List diagnoses in accordance with DSM 5.

First diagnoses
Date of diagnosis (dd/mm/yyyy) *
Are diagnostic criteria currently met? *
Related to transport accident? *
Second diagnoses
Date of diagnosis (dd/mm/yyyy)
Are diagnostic criteria currently met?
Related to transport accident?
add 3rd diagnosis?
Third diagnoses
Date of diagnosis (dd/mm/yyyy)
Are diagnostic criteria currently met?
Related to transport accident?
add 4th diagnosis?
Fourth diagnoses
Date of diagnosis (dd/mm/yyyy)
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 education, 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.

1st goal
(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)
Standardised outcome measures
First outcome measure
Outcome measure name Dates of administration Score Range of scores
Initial date


Mid date


Current date


Add another outcome measure?
Second outcome measure
Outcome measure name Dates of administration Score Range of scores

See tac.vic.gov.au/outcomes
Initial date


Mid date


Current date


Add another outcome measure?
Third outcome measure
Outcome measure name Dates of administration Score Range of scores

See tac.vic.gov.au/outcomes
Initial date


Mid date


Current date


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 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).

See tac.vic.gov.au/outcomes

Refer to Principle 1 of the Clinical Framework.

Example: DASS 21, PCL 5, PSEQ.

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).

See tac.vic.gov.au/outcomes

Refer to Principle 1 of the Clinical Framework.

Example: DASS 21, PCL 5, PSEQ.

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).

See tac.vic.gov.au/outcomes

Refer to Principle 1 of the Clinical Framework.

Example: DASS 21, PCL 5, PSEQ.

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).

See tac.vic.gov.au/outcomes

Refer to Principle 1 of the Clinical Framework.

Example: DASS 21, PCL 5, PSEQ.

Individual treatment requested for approval
Commencement date of the requested services (dd/mm/yyyy) *
Completion date of the requested services (dd/mm/yyyy) *
Group treatment required?
Group treatment requested for approval

Note: The goals of group treatment should be outlined within the Agreed future treatment plan above.

Commencement date of requested services
Completion date of requested services
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 collaboration

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 needs
Has the client returned to pre transport accident employment or study?
Other comments and issues

This may include referral to a psychiatrist, Pain Management Program or other occupational, physical or social/family needs beyond those already expressed in 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
Are you a: *
Supervisor details
Your practice 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.