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Allied Health Professional Template

ACC2126 Training for Independence report

A professional Allied Health Professional template for healthcare professionals.
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Specialty

Allied Health Professional

Used

7 times

Type

Note

Last edited

7/31/2026

Created by

Dr Sarah Manig

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About this template

Streamline your Training for Independence reporting with this comprehensive ACC2126 template, designed for ACC-contracted key workers and Lead Service Providers completing TI plan, variation, and completion reports. It captures report type and service type, supplier and ACC details, client background, injury and non-injury factors, and current function across the client's usual roles. Easily document SMART plan objectives, strategies and outcome measures by discipline, proposed hours and setting, variation reasons, and completion outcomes with ratings against each objective. This template ensures the provider declaration and a structured information gaps review are addressed. Ideal for key workers reporting on Training for Independence programmes, Advisory Services Short-term, and Advisory Services Long-term.

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**Part A: Kiritaki information** **1. Kiritaki details** Kiritaki name: John Smith Date of birth: 03/03/1979 Claim number: ACC000-TESTCLAIM-01 Address: 1 Example Street, Christchurch **Update on treatment and behavioural outcome measures** **Date of Action Plan and/or last Progress Report:** 20/10/2026 **Summary of input provided (eg number of sessions, modality of treatment, type of intervention, frequency)** The kiritaki has attended a further eight sessions of weekly individual psychological treatment since the last report, continuing the cognitive behavioural therapy approach with a focus on trauma-related anxiety, graded exposure to workplace triggers, and relapse-prevention planning as treatment nears completion. **Functional goals** | Goal | Progress | Status | | --- | --- | --- | | Reduce hypervigilance and startle response so the kiritaki can attend the workplace without significant distress (target 4 days/week). | The kiritaki reported reaching and sustaining 4 days per week of workplace attendance over the past four weeks, with minimal residual startle response. | Achieved. | | Improve sleep continuity (target waking no more than once per night). | The kiritaki reported consistently waking no more than once per night for the past six weeks. | Achieved. | **Outline any barriers which are impacting progress:** None reported at this stage. **Reason for more sessions if needed:** The kiritaki has achieved both functional goals set in the previous report. A small number of further sessions are recommended to consolidate gains and support relapse prevention before treatment concludes. **Mental injury assessment (Max. 16 Hours)** Please indicate the proposed next stage: ☐ Treatment with approved mental injury cover (Max. 24 Hours): ☐ Treatment without approved mental injury cover (Max. 10 Hours): ☒ Treatment review (Max. 11 Hours): **New functional goals to be achieved** | Goal | Intervention | Measurement | | --- | --- | --- | | Maintain workplace attendance and sleep gains independently, without ongoing weekly sessions. | Relapse-prevention planning, including a written plan of coping strategies and early-warning signs. | Self-report at a final review session in 8 weeks; repeat DASS-21 Anxiety subscale. | Any other comments or input required for the kiritaki: The kiritaki's presentation has responded well to treatment; no further mental injury assessment is considered necessary. A treatment review is proposed to confirm readiness for discharge. **6. Provider declaration** Provide the date of the last appointment with the kiritaki that informed this report: 15/12/2026 ☒ I have informed the kiritaki that the information collected for this report will be sent to ACC to support cover decisions and treatment and rehabilitation needs. The kiritaki understands this. ☒ I confirm that the information contained in this report is accurate and aligns with ACC's report standards. Date: 15/12/2026 **Psychologist name:** Dr Sigmund Freud Date: 15/12/2026

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