Download Mental health (neuropsychology): treatment plan - MHF3

MENTAL HEALTH (NEUROPSYCHOLOGY):
TREATMENT PLAN
Privacy
Important note
The TAC will retain the information provided and may use or disclose it to
make further inquiries or assist in the ongoing management of the claim or
any claim for common law damages. The TAC may also be required by law
to disclose this information.
To ensure that this plan is promptly considered by the TAC, please type or
use block letters and ensure that all sections are complete. All incomplete
forms will be returned, so please give reasons if you are unable to complete
a section.
Without this information, the TAC may be unable to determine entitlements
or assess whether treatment is reasonable and may not be able to approve
further benefits and treatment.
Please refer to the notes for assistance in completing this form
1. Person details
Person name
Claim number
Person address
Date of birth
/
Date of accident
/
/
/
Post code
2. Referral
Who was the medical practitioner that referred this person to you?
Referrer’s name
Date of referral
/
/
Reason for referral
3. The transport accident
Briefly state the nature of the transport accident according to the person
4. Head injury
Did the person suffer a head injury?
Yes
No
If a significant head injury was sustained please give details of head injury severity indicators (i.e. loss of consciousness), radiological evidence (i.e. findings on
CT scan.) and physical evidence (i.e. hemiplegia). Please note the source of the information and whether any discrepancies exist between different sources.
Please indicate if the information is not known.
Axis
Please note source
Example: person, hospital notes, reports
Head injury severity indicators
Radiological evidence
Physical evidence
5. Current neuropsychological status
On the basis of your assessment, if repeated since the last plan, report information on current status and effects on brain injury on function in the following
areas. Please indicate if those problems are directly related to the transport accident.
Axis
Disability
1. Cognitive
1.
Functional problem
Related to transport
accident?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
2.
3.
2. Behavioural
© Transport Accident Commission 2006
MHF3 0406
60 Brougham Street
GEELONG VIC 3220
Telephone 1300 654 329
STD Toll Free 1800 332 556
PO Box 742
GEELONG VIC 3220
www.tac.vic.gov.au
ABN 22 033 947 623
Ausdoc DX 216079 Geelong
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MENTAL HEALTH (NEUROPSYCHOLOGY):
TREATMENT PLAN
Axis
Disability
Functional problem
Related to transport
accident?
3. Emotional
Yes
No
6. Pre accident status
List this person’s pre accident status, including highest level of education achieved, employment at the time of the transport accident, other significant previous
employment, social status and living arrangements. List pre accident issues including medical conditions.
Pre accident status
1.
Highest level of education
2.
Employment at the time of transport accident
3.
Other significant previous employment
4.
Social situation and living arrangements
5.
Pre existing issues
a) medical conditions
b) cognitive functioning
c) behavioural functioning
d) emotional functioning
e) social functioning
7. Previous neuropsychological assessment and treatment
Name of provider
Date of service
/
Report of assessment received
/
8. Identify other risk factors
List any other priority risk factors likely to be barriers to a return to valued social and occupational roles.
Example: physical, mental, social, cultural, occupational, legal
9. Agreed care plan and measures
What practical goals have been agreed with the person? How will these goals be achieved, by what date, and using what progress measures?
Practical goals
Interventions/strategies
Progress measures
standardised/customised
Estimated date of
achievement or review
1.
2.
© Transport Accident Commission 2006
MHF3 0406
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MENTAL HEALTH (NEUROPSYCHOLOGY):
TREATMENT PLAN
3.
10. Treatment requested for approval
Note: variations or additional treatment to this plan require prior approval by the TAC
Duration of this plan
Total hours of individual mental health treatment
hours
Commencement date
/
/
Total hours of group mental health treatment
hours
Completion date of this treatment plan *mandatory
/
/
Travel time if required
11. Multidisciplinary coordination and medications
List other providers of treatment to this person, including professional and other carers and their interventions including psychotropic medication prescribed.
Other provider/treatments
Names and contact details
Current interventions/medications
Example: physiotherapy, drug name and dose
Date of your last contact
with provider
1.
/
/
2.
/
/
3.
/
/
12. Other comments and issues
Please note any other issues and needs for this person. This may include occupational, physical or social/family needs beyond those that you can address in
sections 3 and 4 or in the treatment plan. The TAC may be able to fund vocational assessment and services where they are related to the transport accident.
Please clearly indicate if you are requesting TAC vocational assistance for this person.
13. Agreement by the psychologist and the person
This plan should be signed jointly by the psychologist and the person to whom they are providing treatment.
Practitioner authorisation
Provider name, address and phone number. Use practice stamp where
possible
Registration number
Qualifications
Days/hours available
Telephone number
This plan has been agreed for the treatment of mental health problems caused by a transport accident that is subject of a claim with the TAC.
Signature of practitioner
Print name
Date
/
/
Person’s authorisation
I agree with the above plan and hereby authorise my psychologist to supply the TAC with information required in this form, and to discuss the contents of this
form and any ongoing issues of my treatment with appropriate representatives of the TAC.
Signature of client, parent or guardian
Print name
Date
/
/
All questions must be answered for this plan to be considered. Please attach any information that may be relevant.
© Transport Accident Commission 2006
MHF3 0406
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