ACC6426 Early Planning report - ACC - Home



Complete this form if you’re a therapist and you’ve finished your Early Planning sessions with the client.

Please return the completed form, along with a signed ACC6242 Early Planning: client confirmation form or ACC6422 Early planning: guardian confirmation form to: sensitiveclaimsproviderreports@acc.co.nz

Part A: Early Planning

|1. Client details |

|Client name:       |Claim number:       |

|Date of birth:       |Address:       |

| Adult | Child or young person |

| Female | Male | Non-binary |

| | |Preferred pronouns/other information:       |

|Ethnicity:       | | |

|Contact details / Safe contact where appropriate:       |

|Oranga Tamariki status, if applicable:       |

|Client’s existing covered injuries:       |

|Please complete the following if the client is a child or young person |

|Guardian/s name/s:       |

|Relationship to client:       |Guardian/s phone number/s:       |

|Guardian/s address/es, if applicable:       |

|What is the legal status of the guardian/s in relation to the client?       |

|Are there any reasons why ACC should not contact the legal guardian/s?       |

|2. Supplier and provider details |

|Supplier name:       |Supplier ID:       |

|Lead Provider name:       |Lead Provider ID:       |

|Provider type: | Psychiatrist | Psychologist | Psychotherapist |

| Counsellor:       |

|3. Client capability |

|Can the client make decisions about their care? Yes No |

|If No, please contact ACC to talk about this. |

|4. Event details |

|Please note that the information about the event/s that we ask for below does not require detailed disclosure by the client at this point. The |

|information is needed primarily to establish whether a Schedule 3 event/s has occurred and if so, when. To protect the privacy of third parties, |

|please refer to them by their relationship to the client, rather than their names. |

|Please briefly describe the: |

|event/s:       |

|date range of the event/s:       |

|frequency of the events (if applicable):       |

|client’s age at the time of the event/s identified as the basis of this mental injury claim:       |

|Did any of the event/s happen in New Zealand? Yes No |

|If No, please provide further information on where the events/s occurred, and why the client was overseas (e.g. were they on holiday, were they |

|living overseas at the time):       |

|In your opinion, is it likely that one or more of the event(s) is listed | Yes | No | Unsure |

|under Schedule 3? | | |call ACC to clarify |

|Does the client have any other active ACC claims of any kind? | Yes | No | Unsure |

| | | |call ACC to clarify |

|5. Client’s current situation |

|A. What has led the client to seek assistance at this time? |

|      |

|B. Please describe the client’s presentation. This can include comments on the client’s medication and overall health, as well as their current |

|emotional, behavioural and social functioning: |

|      |

|C. Please describe the client’s living situation. For example, the client’s current family or whānau situation, their work or school life, their |

|financial position, any current stresses associated with their situation, or the support and expectations of others: |

|      |

|D. Please describe any current risk factors for this client. Please consider all areas including lifestyle and mental health factors: |

|      |

|E. If a risk of harm to self or others, or risk from others has been identified, please provide the Risk Management plan: |

|      |

|F. Are any other agencies involved in the client’s care? Yes No |

|If Yes, please list the agency or agencies involved: |

|      |

|G. Please describe any current barriers to the client accessing services? This can include, but is not limited to, difficulties such as problems |

|with transport or provider availability: |

|      |

|H. Has the client had any prior assistance for mental health conditions? Yes No |

|If Yes, when and where did the client seek help? |

|      |

|I. Are there any cultural or spiritual needs relevant to the client’s therapy? |

|      |

|J. If English isn’t the client’s first language would they like the support of an interpreter? Yes No |

|If Yes, please specify which language:       |

|6. Client’s Personal Wellbeing Index (PWI) |

|Domain |Initial measure |Current measure |

|Date administered: |      |      |

|Life as a whole (optional) |      |      |

|Standard of living |      |      |

|Personal health |      |      |

|Achieving in life |      |      |

|Personal relationships |      |      |

|Personal safety |      |      |

|Community connectedness |      |      |

|Future security |      |      |

|Spirituality and religion (optional) |      |      |

|Personal Wellbeing Index |0.00 |0.00 |

|Fields automatically calculate PWI. Put cursor in field and press F9 to update | | |

|Version of test administered: | Adult | School child | Intellectual disability |

|Additional comments |

|      |

|7. Planning and service requirements |

|Please list the sources of information used in planning so that we can see that all relevant sources of information have been taken into account. |

|Please refer to the Operational Guidelines for more information. |

|      |

|Please indicate which services (and corresponding support services, if applicable) the client is seeking to access next: |

| Support for Next Steps |

| Support to Wellbeing (short term) |

| Cultural Support and Advice | Social Work | Active Liaison | Whānau Support |

| Supported Assessment |

| Cultural Support and Advice | Social Work | Active Liaison | Whānau Support |

| Support to Wellbeing |

| Group-based therapy | Cultural Support and Advice | Whānau Support |

|Social Work |Active Liaison | |

| Maintaining Wellbeing |

| Other services (please explain):       |

|With reference to the information included in Section 5, please briefly outline how you will use each of the services to address the issues you |

|have identified; for Cultural Support and Advice this will include how you will use the service to remove cultural barriers: |

|      |

|8. Planned services and the providers who will deliver these services |

|For each service you have requested please outline in the following table who will deliver each service and the likely number of hours required for|

|each. For Supported Assessment services, please refer to the Operational Guidelines when considering the most appropriate Assessor to deliver this |

|service. |

|For Cultural Support and Advice, please describe how the practitioner you have engaged meets the requirements of being considered an appropriate |

|person in the community determined to have the right level of stature within that community and expertise necessary to facilitate the removal of |

|cultural barriers to a client’s recovery. |

|ACC requires this information to make a decision on the service(s) requested. |

|Service |Provider |Provider discipline |Supplier |Hours requested |

| | |eg Psychotherapist | | |

|      |      |      |      |      |

|      |      |      |      |      |

|      |      |      |      |      |

|      |      |      |      |      |

|      |      |      |      |      |

|Updated report - additional services required (if applicable) |

|      |      |      |      |      |

|      |      |      |      |      |

|9. Support to Wellbeing (short term) recovery goal |

|Please complete the following for the recovery goal if the client is going to Support to Wellbeing (short term) |

|Recovery goal:       |

|Why has this goal been selected?       |

|How will this goal be achieved?       |

|Which practitioners will be involved in achieving this goal?       |

|How will progress towards this goal be measured?       |

|What is the expected time frame for achievement of this goal?       |

|10. Other relevant information |

|Is there any other information relevant to this claim or the client’s needs that ACC should know about? |

|      |

Part B: Supported Assessment plan

|11. Assessment type |

| New mental injury assessment for cover | |

| Mental injury re-assessment – (claim already covered, but a re-assessment is required) |

|Please indicate any other assessment(s) that may be required, eg incapacity, neuropsychological, cognitive assessment, and outline why this |

|assessment is required: |

|      |

|12. Assessment approach |

|Please list any therapists or specialists not in the ISSC who will be involved in the assessment: |

|      |

|Please indicate if the provider completing the assessment is comfortable with beginning the assessment prior to receiving the medical notes from |

|ACC |

| Yes | No. Please outline why not:       |

|Please indicate the proposed initial assessment date:       |

|When do you expect the report to be completed and sent to ACC?       |

Part C: Supporting information and confirmation

|13. Other information |

|Please indicate the date of the last face-to-face meeting with the client that informed this report:       |

|Date of disengagement by the client (if applicable):       |

| I have attached an ACC6242 Early Planning: client confirmation form or an ACC6422 Early planning: guardian confirmation form |

| I have attached an authority to collect information (ACC6300), if necessary |

| I have attached other documents (please list):       |

|14. Provider declaration |

| I have informed the client/guardian/s that the information collected for this report will be sent to ACC [and will be used to inform decision |

|making about support and rehabilitation needs] and I have obtained the client’s/guardian/s authority for this. |

|I confirm that the information contained in this report is accurate and that I have followed the standards as set out in the ISSC Operational |

|Guidelines. |

|Signature (provider): |Date:       |

|Provider name:       |Provider ID:       |

|14. Provider declaration (updated report, if applicable) |

| I have informed the client/guardian/s that the information collected for this report will be sent to ACC [and will be used to inform decision |

|making about treatment and rehabilitation needs] and I have obtained the client’s/guardian/s authority for this. |

|I confirm that the information contained in this report is accurate and that I have followed the standards as set out in the ISSC Operational |

|Guidelines. |

|Signature (provider): |Date:       |

|Provider name:       |Provider ID:       |

When we collect, use and store information, we comply with the Privacy Act 2020 and the Health Information Privacy Code 2020. For further details see ACC’s privacy policy, available at acc.co.nz. We use the information collected on this form to fulfil the requirements of the Accident Compensation Act 2001.

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