ACC268 Psychological Services Completion Report

# ACC268 Psychological Services Completion Report ## Description This ACC268 template is designed for New Zealand ACC-registered psychologists documenting the completion of psychological services provided to an ACC claimant. It captures provider, claimant, and case manager details alongside the original outcome from the referral and a clear record of which functional objectives were achieved. Easily document the Cognitive Behavioural Therapy interventions delivered, any objectives that were not achieved, ongoing support arrangements, and clinician comments at discharge. This template ensures every section of ACC's completion report is captured systematically, supporting clear discharge documentation and continuity of care. Ideal for psychologists closing out a psychological services intervention with a comprehensive, structured completion report. ## Example output **ACC268** **Psychological Services Completion Report** This form is completed by the provider with details of the services provided and the functional objectives achieved. **Provider Details** Provider name: Dr Anya Kapoor Signature: Address (fax number/email): Riverside Psychology Services, 12 Cathedral Junction, Christchurch 8011; fax 03 366 7218; a.kapoor@riversidepsych.co.nz Date: 22/05/2026 **Claimant Details** Claimant's name: Daniel Whitaker Phone number: 027 542 8819 Claim number: 10076458 Date of birth: 09/08/1989 Date of injury: 14/11/2025 **Case Manager Details** Case Manager name: Hayden Whitfield Branch: Christchurch **Psychological Service Details** **Original outcome to be achieved (as per referral):** Resolution of acute stress and adjustment symptoms following Daniel's workplace electrical incident on 14/11/2025, including reduction in intrusive memories and hyperarousal to below clinical threshold, full and sustained return to electrical work duties, restoration of sleep continuity, and re-engagement with social and family activities. **Functional objectives achieved:** | Functional objective achieved | Comments | |-------------------------------|----------| | Return to full electrical work duties on commercial sites | Achieved 28/04/2026. Daniel returned to full duties at Hewitt Electrical and has sustained full hours over a 4 week period without symptom recurrence. | | Restoration of sleep continuity (7 or more hours per night, sleep onset under 30 minutes) | Achieved 14/04/2026 per sleep diary. PSQI improved from 13 at baseline to 5 at session 8. | | Resolution of intrusive memories and hyperarousal | Achieved 21/04/2026. PCL-5 reduced from 41 at baseline to 12, below clinical threshold. | | Re-engagement with social and family activities | Achieved 10/03/2026. Daniel has resumed weekly social activities with his rugby club and family weekends away. | **Cognitive Behavioural Therapy provided:** [x] Relaxation training [ ] Assertiveness training [x] Stress management [ ] Anger management [x] Problem solving training [ ] Social skills training [x] Coping strategies [x] Goal setting [ ] Pain management [x] Other: trauma-focused CBT including imaginal exposure to incident memories and graded in vivo exposure to electrical work environments **Functional objectives not achieved:** | Functional objective not achieved | Comments | |-----------------------------------|----------| | Confident return to live high-voltage work without supervisor present | Partially achieved. Daniel is comfortable with high-voltage work in supervised contexts and reports mild residual anxiety on solo high-voltage tasks. He has chosen to continue with site supervision for the immediate future, with a plan to progress over the next 8 to 12 weeks using the self-management strategies developed in therapy. This is not considered to warrant further ACC-funded sessions. | **Ongoing support in place:** Daniel will continue self-directed use of the CBT-based coping strategies and the relapse-prevention plan developed across sessions. He has written copies of his safety plan and graded exposure hierarchy. His employer's onsite Health and Safety Officer is aware of his return-to-work progression and is available for support if required. Daniel's GP, Dr Marcus Webb, has been notified of completion and provided with a written summary. Daniel has been advised to re-engage with psychological services privately or via GP referral if symptoms return or escalate, and is aware of the ACC pathway for review should it be required. **Other comments:** Daniel demonstrated excellent engagement and rapid progress through the trauma-focused CBT protocol. The graded in vivo exposure component was significantly supported by his employer's flexible return-to-work approach, which allowed gradual reintroduction to electrical work tasks under supervision. He completed all 10 funded sessions and has been discharged today with confidence in his ability to self-manage. No further ACC-funded psychological services are recommended at this time. **Claimant Signature** Claimant signature: Date: 22/05/2026 The information collected on this form will only be used to fulfil the requirements of the Accident Compensation Act 2001. In the collection, use and storage of information, ACC will at all times comply with the obligations of the Privacy Act 1993 and the Health Information Privacy Code 1994. **Items for Clinician Review** - Provider Details, Address: practice address stated verbally without postcode; verify "Christchurch 8011" against Riverside Psychology Services records before submission. - Psychological Service Details, PCL-5 scores: baseline and final values stated verbally as "forty-one" and "twelve"; confirm both match the documented PCL-5 questionnaire results rather than recalled from memory.