ACC268 Psychological Services Completion Report

**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 Sigmund Freud Signature: Address (fax number/email): Berggasse Wellbeing Clinic, admin@berggassewellbeing.co.nz Date: 15/12/2026 **Claimant Details** Claimant's name: John Smith Phone number: 03 555 0199 Claim number: ACC000-TESTCLAIM-01 Date of birth: 03/03/1979 Date of injury: 15/03/2026 **Case Manager Details** Case Manager name: Jane Doe Branch: Christchurch **Psychological Service Details** **Original outcome to be achieved (as per referral):** Reduce trauma-related anxiety and improve sleep disruption to support a full return to workplace duties. **Functional objectives achieved:** | Functional objective achieved | Comments | | --- | --- | | Attend the workplace five days per week without significant anxiety | Achieved; the claimant sustained full workplace attendance over the final four weeks of treatment | | Maintain consistent sleep, waking no more than once per night | Achieved; the claimant reported consistent sleep for six consecutive weeks prior to discharge | **Cognitive Behavioural Therapy provided:** [x] Relaxation training [ ] Assertiveness training [x] Stress management [ ] Anger management [ ] Problem solving training [ ] Social skills training [x] Coping strategies [x] Goal setting [ ] Pain management [ ] Other: **Functional objectives not achieved:** **Ongoing support in place:** The claimant has been referred back to his GP for routine follow-up. No ongoing psychological input is required at this time. **Other comments:** The claimant responded well to treatment throughout, achieving both functional goals set in his treatment plan. Treatment has concluded successfully with no further sessions required. **Claimant Signature** Claimant signature: Date: 15/12/2026 "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 (fax number/email): only an email address was given; no fax number or postal address was mentioned. Confirm whether these should be added. [ ] Claimant Details – Date of injury: 15/03/2026 was inferred as the date of the workplace incident referenced in earlier reports as triggering symptoms, rather than a formally documented date of injury; confirm against the original ACC claim record.