ACC8535 Cover and Wellbeing Plan - child and young person

**ACC8535** **Cover and Wellbeing Plan - child and young person** "This report" "- is for a kiritaki (client) who was aged 17 years and under when this period of service began." "- should be completed during the Cover and Wellbeing Plan sessions by the Lead Service Provider in collaboration with the kiritaki, and a guardian, safe contact or whānau where appropriate." "Please refer to the Sensitive Claims Service Operational Guidelines and report guidelines on our website: [www.acc.co.nz/resources](https://www.acc.co.nz/resources). Return the completed report to sensitiveclaimsreports@acc.co.nz." **Part A: Kiritaki information** **1. Kiritaki details** Kiritaki name: John Smith Date of birth: 15/06/2012 Claim number: ACC000-TESTCLAIM-02 Contact details/safe contact person: Martha Kent (guardian), 03 555 0287 **2. Consent to access the service** Kiritaki aged 0–15 years Gillick competence has been confirmed: [x] Yes [ ] No Child/young person assent obtained: [x] Yes [ ] No Safe contact consent obtained: [x] Yes [ ] No Kiritaki aged 16 years to 17 years, or where Gillick competence has been confirmed Kiritaki consent obtained: [ ] Yes [ ] No Authority to act (if applicable) consent obtained or informed: [ ] Yes [ ] No Any additional points to note: **3. Changes since the Early Supports Plan** a. Have there been any changes to the situation of the kiritaki or their identified needs since the completion of the Early Supports Plan? [x] Yes [ ] No If yes, please describe these in more detail: The kiritaki's guardian reported that he has settled into a new school year and has started attending a weekly after-school sports group, which has provided a positive routine since the Early Supports Plan was completed. b. Are there any areas of risk? Are there any risks identified? [ ] Yes [x] No c. Are any other agencies currently involved in supporting the kiritaki? [ ] Yes [x] No **Part B: Cover determination** **4. Psychometrics** **Measure 1: HoNOSCA / HoNOSI** Name of measure: Health of the Nation Outcome Scales for Children and Adolescents Date administered: 05/09/2026 Section A total score: 9 Section A+B total score: 11 Comments on the HoNOSCA / HoNOSI results: The scores reflect mild to moderate difficulties in the emotional and family relationship domains, consistent with the kiritaki's reported presentation. **Measure 2: Results of additional measures used** | Name of measure | Date administered | Respondents | Score | | --- | --- | --- | --- | | Child Revised Impact of Events Scale | 05/09/2026 | Kiritaki (self-report) | 24 | Comment on results: The score is within the clinically significant range, consistent with the kiritaki's reported intrusive thoughts and avoidance behaviours. **5. Link to Schedule 3 Events** The kiritaki disclosed historical sexual abuse perpetrated by an adult known to the family, occurring over a period of several months, at an approximate frequency of once every few weeks. The kiritaki's guardian reported that his difficulties with sleep, irritability, and reluctance to be alone with unfamiliar adults began during the period the abuse was occurring, and have persisted since. The intrusive thoughts and avoidance behaviours he reports on the Child Revised Impact of Events Scale directly reference reminders of the disclosed events. No other significant sources of trauma, adversity, or major life adjustment were identified. **Part C: Wellbeing Plan** **6. Treatment** a. Tailored treatment needs The kiritaki requires trauma-focused psychological support to address his reported sleep disturbance, irritability, and avoidance behaviours, delivered in an age-appropriate format with his guardian involved in supporting strategies at home. b. Broad treatment outcomes: The kiritaki's guardian reported that they would like to see him sleeping through the night and feeling comfortable participating in his usual activities without distress. This will be considered achieved when the kiritaki reports reduced intrusive thoughts and his guardian observes a return to his previous sleep pattern. **7. Treatment barriers** | Treatment barriers | Plans to address treatment barriers | | --- | --- | | The kiritaki's guardian reported he is sometimes reluctant to talk about his feelings directly. | Sessions will use age-appropriate, indirect approaches such as drawing and play-based techniques to support engagement. | **8. Recovery goals** Recovery goal: Reduce nighttime distress and return to a consistent sleep routine. How will the outcomes of this goal improve kiritaki functioning? The kiritaki will have improved energy and mood during the day and at school. How will this goal be achieved? Weekly individual sessions using trauma-focused, age-appropriate techniques, with guardian coaching on bedtime routine strategies. How will progress towards this goal be measured? Guardian-reported sleep diary and repeat Child Revised Impact of Events Scale at review. Who will deliver the services to support this goal and what is the expected timeframe to achieve this goal? Dr Sigmund Freud, over the next 10 weeks. **9. Planned services and the providers who will deliver these** **Tailored Support to Wellbeing** | Service | Provider name/ACC ID | Provider discipline | Supplier/Supplier ID | Hours | | --- | --- | --- | --- | --- | | Individual psychological treatment | Dr Sigmund Freud / TEST-PROV-01 | Clinical Psychologist | Berggasse Wellbeing Clinic / TEST-SUP-01 | 10 | Total hours of Tailored Support to Wellbeing: **Group-based Therapy** **Other ACC services** Total expected package duration of all services listed above: **Part D: Other information and declarations** **10. Other information** Please provide the date of the last face-to-face meeting with the kiritaki/guardian/whānau that informed this report: Date: 05/09/2026 Please provide the proposed Progress Report submission date: Date: 15/12/2026 Date of disengagement by the kiritaki/guardian/whānau (if applicable): Please provide any other information that you consider relevant to assist in determining cover or to assist in the recovery of the kiritaki: [x] I have attached a completed copy of the HoNOSCA / HoNOSI questionnaire [ ] I have attached other documents, eg clinical reports, other psychometric results. List these: **11. Provider declaration and signature** [x] "I have informed the kiritaki/guardian/safe contact/whānau that the information collected for this report will be sent to ACC to support decisions on treatment and rehabilitation needs. I have kiritaki/guardian/whānau authority for this." [x] "I confirm that the information contained in this report is accurate and that I have followed the standards set out in the Sensitive Claims Service operational guidelines." Lead Service Provider name: Dr Sigmund Freud Provider ID: TEST-PROV-01 Supplier name: Berggasse Wellbeing Clinic Supplier ID: TEST-SUP-01 Date: 05/09/2026 "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." --- **HoNOSCA score sheet** "Report the ratings and result of the clinician version of HoNOSCA in the score sheet below and in section 4 of the Cover and Wellbeing Plan template above. HoNOSCA is for ages 4-17 years." **Date administered:** 05/09/2026 **HoNOSCA section A** 1. Disruptive, antisocial or aggressive behaviour: 1 2. Overactivity attention and concentration: 0 3. Non-accidental self-injury: 0 4. Alcohol, substance/solvent misuse: 0 5. Scholastic or language skills: 0 6. Physical illness or disability problems: 0 7. Hallucinations and delusions: 0 8. Non-organic somatic symptoms: 1 9. Emotional and related symptoms: 3 10. Peer relationships: 1 11. Self-care and independence: 0 12. Family life and relationships: 2 13. Poor school attendance: 1 Section A total score: 9 **HoNOSCA section B** 14. Lack of knowledge – nature of difficulties: 1 15. Lack of information – services/management: 1 Section A + B total score: 11 --- **HoNOSI score sheet** "Report the ratings and result of the clinician version of HoNOSI in the score sheet below and in section 4 of the Cover and Wellbeing Plan template above. HoNOSI is for ages 0-47 months." **Date administered:** **HoNOSI section A** 1. Problems with disruptive behaviour/irritability emotional regulation: 2. Problems with activity levels, joint and/or sustained attention: 3. Non-accidental self-injury or lack of self-protective behaviours: 4. Problems with feeding and eating behaviour: 5. Problems with Developmental delays: 6. Problems with physical illness or disability: 7. Problems associated with regulation and integration of sensory processing: 8. Problems associated with sleep: 9. Problems with emotional and related symptoms or emotional regulation: 10. Problems with social reciprocity: 11. Problems with age-appropriate self-care and environmental exploration: 12. Problems with family life and relationships: 13. Attending care, education and socialisation settings: Section A total score: **HoNOSI section B** 14. Lack of knowledge – nature of difficulties: 15. Lack of information – services/management: Section A + B total score: **Items for Clinician Review** [ ] Section 5 – Link to Schedule 3 Events: the abuse frequency was described only as "once every few weeks" over "several months"; please confirm whether more precise dates are available. [ ] Section 2 – Consent: only the Gillick-competence pathway was completed as the kiritaki is aged 14; please confirm this is the correct pathway given his individual circumstances. [ ] HoNOSI score sheet: left blank as the kiritaki is 14 years old and HoNOSCA (not HoNOSI) applies; confirm this section can remain blank per the form's own age criteria.