ACC266 Psychological services action plan [Updated]

**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 "Contact details/safe contact where appropriate:" Alfred Pennyworth (support person), 03 555 0199 "Gender:" "[x] Male" "[ ] Female" "[ ] Another gender" "[ ] Prefer not to say" "Ethnicity:" New Zealand European "Is the kiritaki able to make decisions about their care? If no, please contact their ACC recovery team member about this." "[x] Yes" "[ ] No" --- **Part B: Event and injury details** **2. Event and injury details** "Documents consulted:" ACC7436 Referral form from Dr Jane Doe, GP **Summary of ACC covered physical and/or mental injuries.** **Reason for referral** The kiritaki was referred for psychological input following a work-related mental injury sustained after witnessing a serious incident at his workplace. The referral, from Dr Jane Doe, GP, states: "Mr Smith presents with significant anxiety and hypervigilance following a traumatic event at work and requires psychological support to assist with his recovery and return to normal functioning." **Presentation** The kiritaki presented as alert and cooperative, though visibly anxious throughout the session, reporting difficulty relaxing since the incident. **History of Injury and Rehabilitation** The kiritaki reported that the injury occurred approximately eight weeks prior to this assessment, when he witnessed a serious accident at his workplace. He stated that he has not yet engaged in any formal psychological treatment prior to this referral. "Does the kiritaki have any other active ACC claims? If unsure, please contact us to clarify." "[ ] Yes" "[x] No" --- **3. Kiritaki current situation, background and treatment needs** "Documents consulted:" Transcript only **a. Brief summary of kiritaki current situation** **Living Situation** The kiritaki reported that he lives alone in a large house on the outskirts of the city, with occasional support from a long-time household employee. He stated that he has a small number of close friends who check in on him regularly. **b. Current concerns, symptoms and difficulties** **Injury related:** * **Headaches:** The kiritaki reported intermittent tension headaches, rating these as 4/10 on average, worse in the evenings. * **Physical Symptoms:** The kiritaki reported disrupted sleep, waking multiple times per night, and ongoing fatigue during the day. * **Cognitive difficulties:** The kiritaki reported some difficulty concentrating on detailed tasks since the incident. * **Mood:** The kiritaki reported feeling anxious and on edge much of the time, with a strong startle response to loud noises. He completed the DASS-21, scoring Depression 8 (mild), Anxiety 14 (severe), Stress 16 (moderate). * **Impact on Functioning:** The kiritaki reported that his anxiety has affected his ability to concentrate at work and has reduced his motivation to attend social events he previously enjoyed. He stated he remains motivated to return to his usual activities. **Non-injury related:** Not mentioned. **c. Cultural and spiritual needs** None reported. **d. Risk identification** "Are there any risks identified?" "[ ] Yes" "[x] No" **e. Other agency involvement** "Are any other agencies currently involved in supporting the kiritaki?" "[ ] Yes" "[x] No" **f. Previous mental health assistance** "Has the kiritaki previously received assistance for their mental health?" "[ ] Yes" "[x] No" **g. Relevant background information** **Employment History** The kiritaki reported that he is self-employed, managing a family business, and has been unable to attend the office as regularly since the incident. **h. Further opinion and recommendations** **Formulation** The kiritaki presents with a trauma-related anxiety response following a workplace incident, characterised by hypervigilance, sleep disturbance, and reduced concentration. Contributing factors include the demands of managing his business independently. Positive prognostic factors include his stated motivation to recover, a stable living situation, and a small but supportive social network. **Recommendation** Trauma-focused psychological treatment is recommended, incorporating psychoeducation and anxiety-management strategies. --- **4. Treatment planning and functional objectives** "**Documents consulted**:" ACC7436 Referral form from Dr Jane Doe, GP "Specific question(s) outlined in ACC Psychological Services referral:" "Please assess and provide psychological treatment to support Mr Smith's recovery and return to normal functioning." The kiritaki reported that his main goal is to feel calmer and to sleep through the night again, so that he can return to running his business without feeling constantly on edge. | Functional goals to be achieved | What type of intervention will be used to achieve functional goals? | How functional goals will be measured (including pre and post psychometric measures) | | --- | --- | --- | | 1. Reduce hypervigilance and startle response so the kiritaki can attend the workplace without significant distress. Currently attending 1 day per week; goal is 4 days per week within 8 weeks. | Psychoeducation on trauma responses, graded exposure, and breathing/relaxation exercises. | Self-reported days attended per week; repeat DASS-21 Anxiety subscale at review. | | 2. Improve sleep continuity. Currently waking 3–4 times per night; goal is waking no more than once per night within 8 weeks. | Sleep hygiene psychoeducation and relaxation-based strategies. | Self-reported sleep diary; kiritaki self-report at review. | "Please indicate the proposed next stage:" "[ ] Mental injury assessment (max. 16 Hours)" "[x] Treatment with approved mental injury cover (max. 24 Hours)" "[ ] Treatment without approved mental injury cover (max. 10 Hours)" | Proposed Session Plan and Supports | Details | | --- | --- | | Number of sessions required | 10 | | Proposed frequency | Weekly | | Target completion date | 15/12/2026 | | Proposed date of next review | 15/10/2026 | --- **5. Provider declaration** "[ ] 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." "Provide the date of the last appointment with the kiritaki that informed this report:" 01/09/2026 "Psychologist name:" Dr Selina Kyle "Date: ___" "In the collection, use, disclosure, and storage of information, ACC will at all times comply with the obligations of the Privacy Act 2020, the Health Information Privacy Code 2020 and the Official Information Act 1982." --- **Information gaps — assessor review required** 1. Section 3d – Risk identification: not explicitly discussed in the transcript beyond a "No" response; assessor should confirm no risk indicators were missed. 2. Section 3g – Drug and Alcohol History, Psychiatric History, Medical History, Medications: none of these were discussed and have been omitted; assessor to confirm whether relevant. 3. Section 4 – Active Liaison and/or Whānau Support, Proposed mental injury assessor, Agreement with prior assessment: not discussed and omitted from the session plan table; assessor to confirm whether applicable.