# ACC268 Psychological Services Completion Report
## Description
This ACC268 template is designed for New Zealand ACC-registered psychologists documenting the completion of psychological services provided to an ACC claimant. It captures provider, claimant, and case manager details alongside the original outcome from the referral and a clear record of which functional objectives were achieved. Easily document the Cognitive Behavioural Therapy interventions delivered, any objectives that were not achieved, ongoing support arrangements, and clinician comments at discharge. This template ensures every section of ACC's completion report is captured systematically, supporting clear discharge documentation and continuity of care. Ideal for psychologists closing out a psychological services intervention with a comprehensive, structured completion report.
## Example output
**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 Anya Kapoor
Signature:
Address (fax number/email): Riverside Psychology Services, 12 Cathedral Junction, Christchurch 8011; fax 03 366 7218; a.kapoor@riversidepsych.co.nz
Date: 22/05/2026
**Claimant Details**
Claimant's name: Daniel Whitaker
Phone number: 027 542 8819
Claim number: 10076458
Date of birth: 09/08/1989
Date of injury: 14/11/2025
**Case Manager Details**
Case Manager name: Hayden Whitfield
Branch: Christchurch
**Psychological Service Details**
**Original outcome to be achieved (as per referral):**
Resolution of acute stress and adjustment symptoms following Daniel's workplace electrical incident on 14/11/2025, including reduction in intrusive memories and hyperarousal to below clinical threshold, full and sustained return to electrical work duties, restoration of sleep continuity, and re-engagement with social and family activities.
**Functional objectives achieved:**
| Functional objective achieved | Comments |
|-------------------------------|----------|
| Return to full electrical work duties on commercial sites | Achieved 28/04/2026. Daniel returned to full duties at Hewitt Electrical and has sustained full hours over a 4 week period without symptom recurrence. |
| Restoration of sleep continuity (7 or more hours per night, sleep onset under 30 minutes) | Achieved 14/04/2026 per sleep diary. PSQI improved from 13 at baseline to 5 at session 8. |
| Resolution of intrusive memories and hyperarousal | Achieved 21/04/2026. PCL-5 reduced from 41 at baseline to 12, below clinical threshold. |
| Re-engagement with social and family activities | Achieved 10/03/2026. Daniel has resumed weekly social activities with his rugby club and family weekends away. |
**Cognitive Behavioural Therapy provided:**
[x] Relaxation training
[ ] Assertiveness training
[x] Stress management
[ ] Anger management
[x] Problem solving training
[ ] Social skills training
[x] Coping strategies
[x] Goal setting
[ ] Pain management
[x] Other: trauma-focused CBT including imaginal exposure to incident memories and graded in vivo exposure to electrical work environments
**Functional objectives not achieved:**
| Functional objective not achieved | Comments |
|-----------------------------------|----------|
| Confident return to live high-voltage work without supervisor present | Partially achieved. Daniel is comfortable with high-voltage work in supervised contexts and reports mild residual anxiety on solo high-voltage tasks. He has chosen to continue with site supervision for the immediate future, with a plan to progress over the next 8 to 12 weeks using the self-management strategies developed in therapy. This is not considered to warrant further ACC-funded sessions. |
**Ongoing support in place:**
Daniel will continue self-directed use of the CBT-based coping strategies and the relapse-prevention plan developed across sessions. He has written copies of his safety plan and graded exposure hierarchy. His employer's onsite Health and Safety Officer is aware of his return-to-work progression and is available for support if required. Daniel's GP, Dr Marcus Webb, has been notified of completion and provided with a written summary. Daniel has been advised to re-engage with psychological services privately or via GP referral if symptoms return or escalate, and is aware of the ACC pathway for review should it be required.
**Other comments:**
Daniel demonstrated excellent engagement and rapid progress through the trauma-focused CBT protocol. The graded in vivo exposure component was significantly supported by his employer's flexible return-to-work approach, which allowed gradual reintroduction to electrical work tasks under supervision. He completed all 10 funded sessions and has been discharged today with confidence in his ability to self-manage. No further ACC-funded psychological services are recommended at this time.
**Claimant Signature**
Claimant signature:
Date: 22/05/2026
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: practice address stated verbally without postcode; verify "Christchurch 8011" against Riverside Psychology Services records before submission.
- Psychological Service Details, PCL-5 scores: baseline and final values stated verbally as "forty-one" and "twelve"; confirm both match the documented PCL-5 questionnaire results rather than recalled from memory.
**ACC268**
**Psychological Services Completion Report**
"This form is completed by the provider with details of the services provided and the functional objectives achieved."
(All checkbox options throughout this form must always appear in the output. Never omit any checkbox options. If a checkbox option is not explicitly mentioned in the transcript, contextual notes, or clinical note, leave it as '[ ]'. Do not remove or hide any checkbox options under any circumstances.)
**Provider Details**
Provider name: [provider's full name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
Signature:
Address (fax number/email): [provider's address, fax number and/or email] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
Date: [date of completion report] (Print the date in DD/MM/YYYY format. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Claimant Details**
Claimant's name: [claimant's full name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
Phone number: [claimant's phone number] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
Claim number: [claimant's ACC claim number] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
Date of birth: [claimant's date of birth] (Print the date in DD/MM/YYYY format. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
Date of injury: [claimant's date of injury] (Print the date in DD/MM/YYYY format. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Case Manager Details**
Case Manager name: [case manager's full name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
Branch: [case manager's branch] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Psychological Service Details**
**Original outcome to be achieved (as per referral):**
[original outcome to be achieved as stated in the referral] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Functional objectives achieved:**
[functional objectives achieved] (Format each functional objective achieved as a new row in a two-column markdown table. The columns are: Functional objective achieved, and Comments. Use a hyphen "-" for any fields that are not mentioned. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Cognitive Behavioural Therapy provided:**
(Mark with '[x]' based on information explicitly mentioned in the transcript, contextual notes, or clinical note. You may mark more than one of the following options. Do not omit any options.)
[ ] Relaxation training (Mark with '[x]' if relaxation training was provided. Leave '[ ]' if not explicitly mentioned. Do not omit any options.)
[ ] Assertiveness training (Mark with '[x]' if assertiveness training was provided. Leave '[ ]' if not explicitly mentioned. Do not omit any options.)
[ ] Stress management (Mark with '[x]' if stress management was provided. Leave '[ ]' if not explicitly mentioned. Do not omit any options.)
[ ] Anger management (Mark with '[x]' if anger management was provided. Leave '[ ]' if not explicitly mentioned. Do not omit any options.)
[ ] Problem solving training (Mark with '[x]' if problem solving training was provided. Leave '[ ]' if not explicitly mentioned. Do not omit any options.)
[ ] Social skills training (Mark with '[x]' if social skills training was provided. Leave '[ ]' if not explicitly mentioned. Do not omit any options.)
[ ] Coping strategies (Mark with '[x]' if coping strategies were provided. Leave '[ ]' if not explicitly mentioned. Do not omit any options.)
[ ] Goal setting (Mark with '[x]' if goal setting was provided. Leave '[ ]' if not explicitly mentioned. Do not omit any options.)
[ ] Pain management (Mark with '[x]' if pain management was provided. Leave '[ ]' if not explicitly mentioned. Do not omit any options.)
[ ] Other: [other CBT intervention provided] (Mark with '[x]' if another CBT intervention not listed above was provided. Leave '[ ]' if not explicitly mentioned. Do not omit any options. Only include placeholder if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder and leave blank)
**Functional objectives not achieved:**
[functional objectives not achieved] (Format each functional objective not achieved as a new row in a two-column markdown table. The columns are: Functional objective not achieved, and Comments. Use a hyphen "-" for any fields that are not mentioned. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Ongoing support in place:**
[description of ongoing support in place for the claimant] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Other comments:**
[other comments regarding the psychological services provided] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Claimant Signature**
Claimant signature:
Date: [date of claimant signature] (Print the date in DD/MM/YYYY format. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
"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**
[checklist of items requiring clinician verification before finalising] (Print each flagged item on its own line beginning with '-' (bullet point), followed by the section name and a brief description of what the clinician needs to verify. Flag any content where review is warranted before sign-off. Examples of what to flag include: identity and demographic details that were unclear, partial, or potentially misheard, such as patient name spelling, NHI number, ACC claim number, date of birth, contact details, or address; dates that were spoken partially or ambiguously, such as "the third of the third" without a year, "last Tuesday" without an explicit date, date of injury, date of first treatment, date of assessment, or follow-up review date; mechanism of injury described vaguely or incompletely, such as "twisted awkwardly" without direction or load, "fell" without specifying surface or height, or a mechanism inferred from outcome rather than stated; diagnoses lacking specificity, such as body region without side, "shoulder pain" without specifying which shoulder, a general diagnosis without laterality, chronicity, or grade, or a working diagnosis where a definitive one is expected; numerical values that were partial, unclear, or potentially misheard, such as pain scores, range of motion in degrees, strength grades, blood pressure readings, medication doses, dosing frequencies, sessions per week, hours per day, percentage ratings, or impairment ratings; codes or classifications mentioned but not clearly stated, such as Read codes, ICD codes, work capacity percentages, whole-person impairment ratings, or ACC-specific category codes; provider details that were not fully stated, such as referring practitioner name and provider number, signing clinician designation, ACC provider ID, or supplier ID; functional capacity or independence ratings where the spoken value was indistinct, where multiple ratings were given without clarifying which was final, or where a rating was implied but not explicitly stated; return-to-work plan elements partially captured, such as target return date, hours per day, days per week, modified duties, lifting or postural restrictions, graduated return phases, or review date; treatment plan details with potential ambiguity, such as medication name, dose, frequency, route, or duration; therapy modality, session count, frequency, or review point; equipment or aid prescriptions without size, model, or supplier; clinical content inferred from context rather than explicitly stated, such as an assumed diagnosis based on described symptoms, an inferred mechanism, an inferred prior medical or surgical history, or an inferred medication based on a condition; conflicting or contradictory information across the transcript, contextual notes or clinical note, such as different dates of injury given at different points, conflicting body regions, conflicting laterality, or conflicting medication details; sections of the ACC form where expected information was not mentioned at all, such as consent confirmation, declaration date, clinician signature, mandatory demographic fields, or required outcome ratings; abbreviations, acronyms, or shorthand terms used by the clinician that may have multiple meanings or were not clearly resolved during the consultation; and any quoted values where the audio was likely affected by background noise, simultaneous speech, or the patient and clinician disagreeing on a detail. For each flagged item, name the section of the form it belongs to and describe the issue in one short sentence. If no items require review based on the transcript, contextual notes or clinical note, print "None flagged." beneath the section heading. Always include this section heading.)
(Always retain all section and sub-section headings in the output, regardless of whether content is available to populate them. If no information is explicitly mentioned for a given section or sub-section, leave the area beneath the heading blank but never remove the heading itself.)
