**ACC8534**
**Cover and Wellbeing Plan - adult**
This report should be completed during the Cover and Wellbeing Plan sessions by the Lead Service Provider in collaboration with the kiritaki (client).
Please refer to the Sensitive Claims Service Operational Guidelines and report guidelines on our website: www.acc.co.nz/resources. Return the completed report to sensitiveclaimsreports@acc.co.nz.
**Part A: Kiritaki information**
**1. Kiritaki details**
Kiritaki name: Anahera Pene
Date of birth: 22/04/1992
Claim number: 10038429
Contact details/safe contact where appropriate: Safe contact via mobile 027 482 1739, weekdays only between 09:00 and 16:00. Email and voicemail are not safe contact methods.
**2. 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:
Anahera has separated from her partner since the Early Supports Plan was completed and has moved into her sister's home in Hamilton. She is no longer working full-time and has reduced to 0.6 FTE in her administration role. She has also commenced sertraline 50 mg daily under her GP's care, which was not in place at the time of the Early Supports Plan.
b. Are there any areas of risk? Please complete a risk assessment, considering the following risks:
- Is there a risk to self?
- Does the kiritaki pose a risk to others?
- Is the kiritaki at risk of harm from others?
Are there any risks identified?
[x] Yes [ ] No
If yes, please describe the risk and any duty of care actions that have been taken.
Anahera reports passive suicidal ideation without active intent or plan, present intermittently over the past six weeks. No risk to others identified. No current risk of harm from others; the relationship she has left was not described as abusive but had become emotionally distressing. Safety planning has been completed jointly with Anahera, including identification of supportive contacts (her sister and her GP), removal of stockpiled medication from the home, and agreement to contact 1737 or attend Waikato Hospital ED if ideation escalates. Her GP has been notified with her consent and is reviewing her in two weeks.
c. Are any other agencies currently involved in supporting the kiritaki?
[x] Yes [ ] No
If yes, please list the agencies involved, eg Community Mental Health and Addiction Services.
Hamilton GP practice (Dr Hema Singh, Five Cross Roads Medical Centre): medication management and primary care.
Te Whatu Ora Waikato Mental Health and Addiction Services: triaged, not currently open to specialist services; available for re-referral if risk escalates.
**Part B: Cover determination**
**3. Psychometrics – Complete with the kiritaki**
To help confirm the presence of mental injury symptoms caused by Schedule 3 events, please provide a copy of the Impact of Events Scale (IES-R) questionnaire to the kiritaki and ensure they have a private space and sufficient time to complete the questionnaire.
Name of measure: IES-R
Date administered: 19/05/2026
IES-R total score: 48
Comments on the IES-R results:
The kiritaki's total IES-R score of 48 falls within the severe range and is consistent with clinically significant trauma-related symptoms. The intrusion subscale was elevated, reflecting frequent unwanted memories, images, and emotional reactions triggered by reminders. The avoidance subscale was similarly elevated, with active efforts to avoid reminders, suppress thoughts, and emotionally distance from the events. The hyperarousal subscale was elevated, with reported sleep disturbance, irritability, hypervigilance, and difficulties with concentration. The score is consistent with the symptoms described by the kiritaki during clinical interview.
Please include any other symptoms that are not captured by the Impacts of Events Scale but have been reported by the kiritaki:
Anahera reports dissociative episodes lasting up to 20 minutes, occurring two to three times per week, typically triggered by sensory reminders. She describes a pervasive sense of shame and a reduced ability to experience positive emotions. She reports difficulty trusting others, particularly in close relationships, and a preference for social withdrawal. Appetite is reduced and she has lost approximately 4 kg over the past three months.
**4. Link to Schedule 3 events**
Please describe evidence of the causal link between the Schedule 3 events and the presenting symptoms, making sure to consider the following:
- The kiritaki history and psychometric scores gathered through this report.
- Presenting symptoms. Refer to the symptoms directly rather than an overall clinical diagnosis.
- Any other potential causes for the presenting symptoms, eg the impacts on their emotional, behavioural, cognitive, and/or interpersonal functioning.
- Onset of presenting symptoms and what triggers them.
- Progression of presenting symptoms across time including when symptoms get better or worse.
- Themes and content of the kiritaki symptoms, eg how do the Schedule 3 events appear in the symptoms of distress for the kiritaki? Intrusive images, triggers, avoidance.
Anahera's presenting symptoms include intrusive memories specifically related to the Schedule 3 events described in her Early Supports Plan, with intrusive images that match the sensory content of those events (specific smells, voices, and visual details). She avoids locations, people, and conversations that act as direct reminders. Hyperarousal symptoms, including disrupted sleep, hypervigilance, and exaggerated startle response, were first reported in her late teens, approximately two years after the events ceased, and have intensified in the past 12 months following an unrelated trigger (an article she encountered online). The symptoms get worse around anniversaries and following exposure to media coverage of similar events; they ease in periods when she has predictable routines and supportive contact with her sister. Her psychometric score on the IES-R is consistent with the clinical interview and reflects significant intrusion, avoidance, and hyperarousal directly tied to the Schedule 3 events rather than to a non-specific stress response.
Please describe any non-Schedule 3 factors you think have contributed to the symptoms reported by the kiritaki. Make it clear if in your clinical opinion these factors have been more significant than the Schedule 3 events. Examples of non-Schedule 3 factors are:
- Earlier events of sexual abuse when living overseas (not ordinarily resident in New Zealand).
- Other sources of social trauma, adversity or major adjustment.
- Resurfacing of pre-existing distress or other life events, eg grief, loss, separation.
Anahera has experienced significant non-Schedule 3 stressors in the past year, including her recent relationship separation and her move from Tauranga to Hamilton. The death of her grandmother in late 2025 was a meaningful loss. These factors have contributed to a worsening of her overall distress but are not, in the clinician's opinion, the primary cause of her trauma-related symptoms. The content, themes, and triggers of her intrusion and avoidance symptoms map specifically onto the Schedule 3 events and not onto the recent life stressors. The recent stressors are best characterised as contributing to a reduction in her usual coping resources rather than as independent causes of the presenting symptoms.
**Part C: Wellbeing Plan**
**5. Treatment**
a. Tailored treatment needs
The symptoms impacting Anahera's functioning and quality of life include intrusive memories, avoidance, hyperarousal, sleep disturbance, dissociation, shame, social withdrawal, and reduced concentration affecting her work performance. These symptoms have led to reduced work hours, social isolation, and disengagement from activities she previously enjoyed. The supports needed include trauma-focused psychological therapy as the primary intervention, ongoing GP input for medication review and physical health, and engagement with kaupapa Māori support to incorporate her cultural identity into recovery. Anahera has identified that connection with her marae and access to karakia at key points in her therapy are important to her. The treatment plan incorporates a kaupapa Māori practitioner working alongside the lead clinician for cultural support and karakia at the beginning of phase-based work. Anahera has also asked for the option of bringing her sister to one session per month as a support person, which will be accommodated.
b. Broad treatment outcomes:
Anahera would like to be able to engage in close relationships without persistent fear or shame, return to full-time work, and re-engage with her cultural community without the avoidance she currently experiences. She will know this has been achieved when she can attend whānau gatherings without prolonged dread, sleep through most nights, and discuss her experiences with her sister or therapist without dissociating.
c. What other non-ACC supports in the community will be involved in the treatment pathway for the kiritaki?
| Name | Role/function | Community organisation |
|---|---|---|
| Dr Hema Singh | GP, medication review and physical health | Five Cross Roads Medical Centre, Hamilton |
| Whaea Mereana Tuhua | Cultural support, karakia, whānau engagement | Te Hauora o Ngāti Hauā |
| Sarah Pene | Identified support person (sister) | Personal support |
**6. Treatment barriers**
| Treatment barriers | Plans to address treatment barriers |
|---|---|
| Active passive suicidal ideation requires stabilisation before trauma processing | Phase one of therapy will focus on safety planning, stabilisation, and skills for managing distress before any trauma-focused work commences. Regular review of risk at each session. |
| Sleep disruption limiting capacity for between-session work | Sleep hygiene work in early sessions; coordinate with GP regarding medication review for sleep if non-pharmacological measures are insufficient. |
| Geographic distance from previous social supports following relocation | Identify Hamilton-based supports including a peer support group through Te Whatu Ora Waikato when Anahera is ready. |
| Discomfort with in-person therapy initially | First four sessions to be offered via secure video with option to transition to in-person from session five onward, at Anahera's pace. |
**7. Recovery goals**
Please describe the recovery goals you have developed with the kiritaki. The goals should be SMART, that is, Specific, Measurable, Action-oriented, Realistic, and Time-bound; meaningful to the kiritaki; relevant to the recovery of the kiritaki; building progress towards the broad end goal. Avoid goals that can't be achieved within the duration of Tailored Support to Wellbeing Package A.
Recovery goal: Reduce frequency of dissociative episodes from two to three per week to one or fewer per fortnight, by the end of Package A (approximately week 24).
How will the outcomes of this goal improve kiritaki functioning?
Reduced dissociation will allow Anahera to remain present during work tasks, conversations with her sister, and social interactions. She will be able to complete a full work day without losing time, and to attend whānau gatherings without disengaging.
How will this goal be achieved? Specify the services needed and how they will be used to achieve the goal.
Phase one of trauma-focused psychological therapy will introduce grounding skills, present-moment anchoring techniques, and a personalised dissociation management plan. Weekly individual sessions with the Lead Service Provider for the first 12 weeks, with cultural support from Whaea Mereana at sessions 1, 6, and 12.
How will progress towards this goal be measured?
Weekly self-report dissociation diary completed by Anahera and reviewed in each session. Re-administration of relevant subscale of the IES-R at week 12 and week 24.
Who will deliver the services to support this goal and what is the expected timeframe to achieve this goal?
Dr Te Aroha Wikaira (Clinical Psychologist, Lead Service Provider) over weeks 1 to 24. Whaea Mereana Tuhua (cultural support) at agreed cultural touchpoints.
Recovery goal: Return to 1.0 FTE in administration role by week 20, with sustainable workload and no use of sick leave for trauma-related symptoms for at least four consecutive weeks.
How will the outcomes of this goal improve kiritaki functioning?
Returning to full-time work will restore Anahera's financial independence, structure, and sense of vocational identity, all of which she has identified as important to her wellbeing. It will also reduce her financial stress, which is currently a significant contributor to her overall distress.
How will this goal be achieved? Specify the services needed and how they will be used to achieve the goal.
Graduated increase from 0.6 to 1.0 FTE over weeks 12 to 20, in consultation with her employer's HR team and GP. Concurrent skills-based therapy focused on workplace concentration, emotional regulation during work hours, and managing triggers in the office environment.
How will progress towards this goal be measured?
Hours worked per week recorded by Anahera and reviewed monthly. Sick leave used for trauma-related symptoms recorded. Employer feedback at week 20.
Who will deliver the services to support this goal and what is the expected timeframe to achieve this goal?
Dr Te Aroha Wikaira (Clinical Psychologist, Lead Service Provider) in collaboration with Dr Hema Singh (GP) over weeks 12 to 20.
**8. Planned services and the providers who will deliver these**
List the services required under Tailored Support to Wellbeing Package A to meet the recovery goals listed above. Please list any requests for other ACC services to support the recovery of the kiritaki, eg rongoā Māori, or other social rehabilitation, eg childcare.
**Tailored Support to Wellbeing**
| Service | Provider name/ACC ID | Provider discipline | Supplier/Supplier ID | Hours |
|---|---|---|---|---|
| Individual trauma-focused psychological therapy | Dr Te Aroha Wikaira / NZP4827 | Clinical Psychologist | Awhi Mai Psychology Services / S18472 | 24 |
| Cultural support and karakia | Whaea Mereana Tuhua / K20913 | Kaitiaki, kaupapa Māori support | Te Hauora o Ngāti Hauā / S22041 | 6 |
Total hours of Tailored Support to Wellbeing: 30
**Group-based Therapy**
| Service | Provider name/ACC ID | Provider discipline | Supplier/Supplier ID | Hours |
|---|---|---|---|---|
| Women's trauma recovery group, phase two | Dr Te Aroha Wikaira and co-facilitator Ana Whitford / NZP4827 / NZP5119 | Clinical Psychologists | Awhi Mai Psychology Services / S18472 | 16 |
Expected start and end dates of Group-based Therapy: 18/08/2026 to 03/11/2026
**Other ACC services**
| Service | Provider name/ACC ID | Provider discipline | Supplier/Supplier ID | Hours |
|---|---|---|---|---|
| Rongoā Māori | Tipene Hetaraka / R10287 | Rongoā practitioner | Te Hauora o Ngāti Hauā / S22041 | 4 |
Total expected package duration of all services listed above: 24 weeks
If other ACC services have been listed in the table above, please describe how these services will support the recovery of the kiritaki:
Rongoā Māori has been requested by Anahera as a culturally aligned support that sits alongside her psychological therapy. Tipene Hetaraka will provide rongoā at three to four touchpoints across the package, including at the beginning of phase two trauma processing and at the conclusion of the group-based therapy. This supports Anahera's identified need to integrate her cultural identity into her recovery and complements the karakia and whānau-based support provided by Whaea Mereana.
**Part D: Other information and declarations**
**9. Other information**
Please provide the date of the last face-to-face meeting with the kiritaki that informed this report:
Date: 26/05/2026
Please provide the proposed Progress Report submission date:
Date: 18/08/2026
Date of disengagement by the kiritaki (if applicable):
Date:
Please provide any other information that you consider relevant to assist in determining cover or to assist in the recovery of the kiritaki:
Anahera has expressed a clear preference for a female clinician with experience in kaupapa Māori practice, which has been accommodated. She has also asked that any correspondence from ACC be sent to her sister's address rather than her current temporary residence; this is recorded with her consent.
[x] I have attached a completed copy of the Impact of Events Scale (IES-R) questionnaire
[x] I have attached other relevant documents, eg clinical reports, other psychometric results. List these: GP letter from Dr Hema Singh dated 14/05/2026; safety plan dated 21/05/2026.
**10. Provider declaration**
[x] I have informed the kiritaki that the information collected for this report will be sent to ACC to support cover decisions and treatment and rehabilitation needs. I have kiritaki 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 Te Aroha Wikaira
Provider ID: NZP4827
Supplier name: Awhi Mai Psychology Services
Supplier ID: S18472
Date: 28/05/2026
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.
---
**Impact of Events Scale (IES-R) – Kiritaki to complete**
Instructions:
Below is a list of difficulties people sometimes have after a stressful life event. This questionnaire asks you to think about these difficulties as they relate to the Schedule 3 events outlined in your Early Supports Plan and consider how much you are distressed or bothered by any of the difficulties listed below when you think about the impact of these events.
Please read each item and indicate how distressing each difficulty has been for you during the past SEVEN days.
Not at all=0, Little bit=1, Moderately=2, Quite a bit=3, Extremely=4
1. Any reminder brought back feelings about it: 3
2. I had trouble staying asleep: 3
3. Other things kept making me think about it: 2
4. I felt irritable and angry: 2
5. I avoided letting myself get upset when I thought about it or was reminded of it: 2
6. I thought about it when I didn't mean to: 3
7. I felt as if it hadn't happened or wasn't real: 1
8. I stayed away from reminders about it: 3
9. Pictures about it popped into my mind: 2
10. I was jumpy and easily startled: 2
11. I tried not to think about it: 3
12. I was aware that I still had a lot of feelings about it, but I didn't deal with them: 2
13. My feelings about it were kind of numb: 2
14. I found myself acting or feeling like I was back at that time: 1
15. I had trouble falling asleep: 3
16. I had waves of strong feelings about it: 2
17. I tried to remove it from my memory: 3
18. I had trouble concentrating: 2
19. Reminders of it cause me to have physical reactions such as sweating, trouble breathing: 2
20. I had dreams about it: 2
21. I felt watchful and on-guard: 2
22. I tried not to talk about it: 1
Total score: 48
(Add together all 22 responses to get the total score between 0-88)
Please add the total score to Section 3 of the Cover and Wellbeing Plan template above.
**Items for Clinician Review**
- Section 1, Kiritaki details: contact details listed mobile 027 482 1739; confirm whether SMS is a safe contact channel or whether voice only is preferred.
- Section 5c, non-ACC community supports: cultural support practitioner ID for Whaea Mereana recorded as K20913; verify against ACC kaitiaki register before submission.
- Section 8, Tailored Support to Wellbeing hours: 24 hours of individual therapy + 6 hours cultural support = 30 hours total recorded; confirm this aligns with the agreed Package A allocation.
- Section 8, Group-based Therapy: co-facilitator Ana Whitford ACC ID NZP5119 to be verified; this was a recently added co-facilitator and the ID was confirmed verbally only.
- Section 9: Progress Report submission date 18/08/2026 aligns with the start of group-based therapy; confirm this timing is appropriate or whether a slightly later date would better capture early group progress.
- IES-R item-level scores: scores were transcribed from the kiritaki's handwritten questionnaire; cross-check against the original before scanning and attaching.
**ACC8534**
**Cover and Wellbeing Plan - adult**
"This report should be completed during the Cover and Wellbeing Plan sessions by the Lead Service Provider in collaboration with the kiritaki (client)."
"Please refer to the Sensitive Claims Service Operational Guidelines and report guidelines on our website: www.acc.co.nz/resources. Return the completed report to sensitiveclaimsreports@acc.co.nz."
**Part A: Kiritaki information**
**1. Kiritaki details**
Kiritaki name: [kiritaki'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)
Date of birth: [kiritaki'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)
Claim number: [kiritaki'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)
Contact details/safe contact where appropriate: [kiritaki's contact details or safe contact details where appropriate] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**2. 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?
[ ] Yes [ ] No (If there have been changes to the situation of the kiritaki or their identified needs since the completion of the Early Supports Plan as mentioned in the transcript, contextual notes, or clinical note, mark '[x]' for Yes. If there have been no changes, mark '[x]' for No, and leave '[ ]' for information not explicitly mentioned.)
If yes, please describe these in more detail:
[description of changes to the situation of the kiritaki or their identified needs since the Early Supports Plan] (Only include if changes since the Early Supports Plan is marked '[x]' for Yes and details are explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
b. Are there any areas of risk? Please complete a risk assessment, considering the following risks:
"- Is there a risk to self?"
"- Does the kiritaki pose a risk to others?"
"- Is the kiritaki at risk of harm from others?"
Are there any risks identified?
[ ] Yes [ ] No (If any risks are identified as mentioned in the transcript, contextual notes, or clinical note, mark '[x]' for Yes. If no risks are identified, mark '[x]' for No, and leave '[ ]' for information not explicitly mentioned.)
If yes, please describe the risk and any duty of care actions that have been taken.
[description of risks identified and any duty of care actions taken] (Only include if risks identified is marked '[x]' for Yes and details are explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
c. Are any other agencies currently involved in supporting the kiritaki?
[ ] Yes [ ] No (If other agencies are currently involved in supporting the kiritaki as mentioned in the transcript, contextual notes, or clinical note, mark '[x]' for Yes. If no other agencies are involved, mark '[x]' for No, and leave '[ ]' for information not explicitly mentioned.)
If yes, please list the agencies involved, eg Community Mental Health and Addiction Services.
[agencies currently involved in supporting the kiritaki] (List each agency involved. Only include if other agencies involved in supporting the kiritaki is marked '[x]' for Yes and details are explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Part B: Cover determination**
**3. Psychometrics – Complete with the kiritaki**
"To help confirm the presence of mental injury symptoms caused by Schedule 3 events, please provide a copy of the Impact of Events Scale (IES-R) questionnaire to the kiritaki and ensure they have a private space and sufficient time to complete the questionnaire."
Name of measure: IES-R
Date administered: [date the Impact of Events Scale – Revised was administered] (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)
IES-R total score: [Impact of Events Scale – Revised total score] (Always include this field. Do not calculate the total score. Only document the score if it is explicitly stated in the transcript, contextual notes or clinical note. If not explicitly stated, leave blank. This score should correspond to the total in the Impact of Events Scale – Revised score sheet at the end of this report.)
Comments on the IES-R results:
[comments on Impact of Events Scale – Revised results] (Describe and comment on the psychometric results and their clinical significance. Use third person. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
Please include any other symptoms that are not captured by the Impacts of Events Scale but have been reported by the kiritaki:
[other symptoms not captured by the Impact of Events Scale but reported by the kiritaki] (Describe any additional symptoms reported by the kiritaki that are not captured by the Impact of Events Scale – Revised. Use third person. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**4. Link to Schedule 3 events**
"Please describe evidence of the causal link between the Schedule 3 events and the presenting symptoms, making sure to consider the following:"
"- The kiritaki history and psychometric scores gathered through this report."
"- Presenting symptoms. Refer to the symptoms directly rather than an overall clinical diagnosis."
"- Any other potential causes for the presenting symptoms, eg the impacts on their emotional, behavioural, cognitive, and/or interpersonal functioning."
"- Onset of presenting symptoms and what triggers them."
"- Progression of presenting symptoms across time including when symptoms get better or worse."
"- Themes and content of the kiritaki symptoms, eg how do the Schedule 3 events appear in the symptoms of distress for the kiritaki? Intrusive images, triggers, avoidance."
[evidence of causal link between Schedule 3 events and presenting symptoms] (Describe the evidence of the causal link, covering the kiritaki's history and psychometric scores, presenting symptoms referred to directly rather than as an overall clinical diagnosis, any other potential causes, onset and triggers, progression over time, and themes and content of symptoms. Use third person. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
"Please describe any non-Schedule 3 factors you think have contributed to the symptoms reported by the kiritaki. Make it clear if in your clinical opinion these factors have been more significant than the Schedule 3 events. Examples of non-Schedule 3 factors are:"
"- Earlier events of sexual abuse when living overseas (not ordinarily resident in New Zealand)."
"- Other sources of social trauma, adversity or major adjustment."
"- Resurfacing of pre-existing distress or other life events, eg grief, loss, separation."
[non-Schedule 3 factors contributing to symptoms] (Describe any non-Schedule 3 factors that have contributed to the kiritaki's symptoms. Make clear whether in the clinician's opinion these factors have been more significant than the Schedule 3 events. Use third person. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Part C: Wellbeing Plan**
**5. Treatment**
a. Tailored treatment needs
"Please describe what treatment is needed to address the symptoms and functional difficulties of the kiritaki. Include the following information:"
"- What symptoms are impacting the functioning and quality of life of the kiritaki."
"- The supports needed to address the symptoms and improve the functioning and quality of life of the kiritaki, eg GP input for medication, community group engagement, alternative housing."
"- Include any cultural and spiritual needs identified in the Early Supports Plan and describe how these needs will be met within the treatment plan."
[tailored treatment needs] (Describe the treatment needed to address the kiritaki's symptoms and functional difficulties, covering what symptoms are impacting functioning and quality of life, the supports needed, and any cultural and spiritual needs and how they will be met within the treatment plan. Use third person. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
b. Broad treatment outcomes:
"Broad treatment outcomes will identify what the kiritaki would like to be able to do differently or better at the completion of successful mental injury support and treatment. How will the kiritaki know this has been achieved?"
[broad treatment outcomes] (Describe the broad treatment outcomes, including what the kiritaki would like to be able to do differently or better at the completion of treatment and how the kiritaki will know this has been achieved. Use third person. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
c. What other non-ACC supports in the community will be involved in the treatment pathway for the kiritaki? What role will they take? Eg a key worker at Community Mental Health Service completing telephone check-ins.
[non-ACC community supports involved in the treatment pathway] (Format each non-ACC community support as a new row in a three-column markdown table. The columns are: Name, Role/function, and Community organisation. Include as many rows as 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)
**6. Treatment barriers**
"Treatment barriers can reduce the likelihood of achieving outcomes and improving recovery. These barriers can exist in access, delivery and care of the kiritaki."
"Where comorbidities are complex, referrals to specialist teams or support in the community should be identified to improve the likelihood of achieving outcomes and improving recovery."
"Please describe potential and actual barriers that exist and how you plan to address and manage these. Addressing treatment barriers can be completed prior to, or alongside targeting the recovery goals, depending on the barrier. Examples may include lifting depressed mood before trauma processing and addressing safety in the home before commencing trauma work."
[treatment barriers and plans to address them] (Format each treatment barrier as a new row in a two-column markdown table. The columns are: Treatment barriers, and Plans to address treatment barriers. Include as many rows as 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)
**7. Recovery goals**
"Please describe the recovery goals you have developed with the kiritaki."
"The goals should be:"
"- '**<u>SMART</u>**', that is, **<u>S</u>**pecific, **<u>M</u>**easurable, **<u>A</u>**ction-oriented, **<u>R</u>**ealistic, and **<u>T</u>**ime-bound"
"- meaningful to the kiritaki"
"- relevant to the recovery of the kiritaki"
"- building progress towards the broad end goal."
"Avoid goals that can't be achieved within the duration of Tailored Support to Wellbeing Package A."
"If further recovery goals are identified, copy and paste the recovery goal table below this section."
(Repeat the five placeholders below as a group for each recovery goal discussed. Include as many goals as mentioned in the transcript, contextual notes or clinical note.)
Recovery goal: [recovery goal description] (Describe the recovery goal. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
How will the outcomes of this goal improve kiritaki functioning? eg what will the kiritaki be able to do differently or better? [how the outcomes of this goal will improve kiritaki functioning including what the kiritaki will be able to do differently or better] (Describe how achieving this goal will improve functioning. Use third person. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
How will this goal be achieved? Specify the services needed and how they will be used to achieve the goal. [how this goal will be achieved including services needed and how they will be used] (Describe how the goal will be achieved, specifying services needed and how they will be used. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
How will progress towards this goal be measured? [how progress towards this goal will be measured] (Describe how progress will be measured. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
Who will deliver the services to support this goal and what is the expected timeframe to achieve this goal? [who will deliver the services and the expected timeframe to achieve this goal] (Describe who will deliver the services and the expected timeframe. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**8. Planned services and the providers who will deliver these**
"List the services required under Tailored Support to Wellbeing Package A to meet the recovery goals listed above."
"Please list any requests for other ACC services to support the recovery of the kiritaki, eg rongoā Māori, or other social rehabilitation, eg childcare."
**Tailored Support to Wellbeing**
[tailored support to wellbeing services and providers] (Format each tailored support to wellbeing service as a new row in a five-column markdown table. The columns are: Service, Provider name/ACC ID, Provider discipline, Supplier/Supplier ID, and Hours. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
Total hours of Tailored Support to Wellbeing: [total hours of tailored support to wellbeing] (Always include this field. Do not calculate the total. Only document the total if it is explicitly stated in the transcript, contextual notes or clinical note. If not explicitly stated, leave blank.)
**Group-based Therapy**
[group-based therapy services and providers] (Format each group-based therapy service as a new row in a five-column markdown table. The columns are: Service, Provider name/ACC ID, Provider discipline, Supplier/Supplier ID, and Hours. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
Expected start and end dates of Group-based Therapy: [expected start and end dates of group-based therapy] (Print dates 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)
**Other ACC services**
[other ACC services and providers] (Format each other ACC service as a new row in a five-column markdown table. The columns are: Service, Provider name/ACC ID, Provider discipline, Supplier/Supplier ID, and Hours. Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
Total expected package duration of all services listed above: [total expected package duration of all services] (Always include this field. Do not calculate the total. Only document the total if it is explicitly stated in the transcript, contextual notes or clinical note. If not explicitly stated, leave blank.)
If other ACC services have been listed in the table above, please describe how these services will support the recovery of the kiritaki:
[description of how other ACC services will support the recovery of the kiritaki] (Only include if other ACC services have been listed and details are explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
**Part D: Other information and declarations**
**9. Other information**
Please provide the date of the last face-to-face meeting with the kiritaki that informed this report:
Date: [date of last face-to-face meeting with the kiritaki] (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)
Please provide the proposed Progress Report submission date:
Date: [proposed Progress Report submission date] (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 disengagement by the kiritaki (if applicable):
Date: [date of disengagement by the kiritaki] (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)
Please provide any other information that you consider relevant to assist in determining cover or to assist in the recovery of the kiritaki:
[other relevant information to assist in determining cover or recovery of the kiritaki] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
(Mark with '[x]' for each attachment confirmed in the transcript, contextual notes, or clinical note, and leave '[ ]' for information not explicitly mentioned.)
[ ] I have attached a completed copy of the Impact of Events Scale (IES-R) questionnaire (Mark with '[x]' if a completed copy of the Impact of Events Scale – Revised questionnaire is confirmed as attached in the transcript, contextual notes, or clinical note, and leave '[ ]' for information not explicitly mentioned.)
[ ] I have attached other relevant documents, eg clinical reports, other psychometric results. List these: [list of other attached documents] (Mark with '[x]' if other documents are confirmed as attached in the transcript, contextual notes, or clinical note, and leave '[ ]' for information not explicitly mentioned. If marked, list the documents attached.)
**10. Provider declaration**
[ ] "I have informed the kiritaki that the information collected for this report will be sent to ACC to support cover decisions and treatment and rehabilitation needs. I have kiritaki authority for this." (Mark with '[x]' if the provider has informed the kiritaki and has their authority as mentioned in the transcript, contextual notes, or clinical note, and leave '[ ]' for information not explicitly mentioned.)
[ ] "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." (Mark with '[x]' if the provider confirms the information is accurate and the Sensitive Claims Service operational guidelines standards have been followed as mentioned in the transcript, contextual notes, or clinical note, and leave '[ ]' for information not explicitly mentioned.)
Lead Service Provider name: [lead service 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)
Provider ID: [lead service provider's provider ID] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; else omit placeholder, retain section heading and lead-in, and leave blank)
Supplier name: [supplier company 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)
Supplier ID: [supplier ID] (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 declaration] (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)
"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."
---
**Impact of Events Scale (IES-R) – Kiritaki to complete**
"Instructions:"
"Below is a list of difficulties people sometimes have after a stressful life event. This questionnaire asks you to think about these difficulties as they relate to the Schedule 3 events outlined in your Early Supports Plan and consider how much you are distressed or bothered by any of the difficulties listed below when you think about the impact of these events."
"Please read each item and indicate how distressing each difficulty has been for you during the past SEVEN days."
"Not at all=0, Little bit=1, Moderately=2, Quite a bit=3, Extremely=4"
"1. Any reminder brought back feelings about it"
"2. I had trouble staying asleep"
"3. Other things kept making me think about it"
"4. I felt irritable and angry"
"5. I avoided letting myself get upset when I thought about it or was reminded of it"
"6. I thought about it when I didn't mean to"
"7. I felt as if it hadn't happened or wasn't real"
"8. I stayed away from reminders about it"
"9. Pictures about it popped into my mind"
"10. I was jumpy and easily startled"
"11. I tried not to think about it"
"12. I was aware that I still had a lot of feelings about it, but I didn't deal with them"
"13. My feelings about it were kind of numb"
"14. I found myself acting or feeling like I was back at that time"
"15. I had trouble falling asleep"
"16. I had waves of strong feelings about it"
"17. I tried to remove it from my memory"
"18. I had trouble concentrating"
"19. Reminders of it cause me to have physical reactions such as sweating, trouble breathing"
"20. I had dreams about it"
"21. I felt watchful and on-guard"
"22. I tried not to talk about it"
"Total score:"
"(Add together all 22 responses to get the total score between 0-88)"
"Please add the total score to Section 3 of the Cover and Wellbeing Plan template above."
**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.)
