Psychologists and Counsellors' Guide to WorkCover NSW

4. Clinical assessment
Diagnosis (if applicable):�������������������������������������������������������������������������������

5. Barriers to return to pre-injury duties/activity: Strategies to address barrier:
Barrier:

6. Progress Strategies used and progress made:
Outline treatment provided & progress made
Goals:

7. Treatment planning Proposed treatment strategies:
a. Proposed goals
Functional treatment goals (SMART):

b. What self management strategies is the injured person successfully applying?

c. What other parties have you, or will you contact? (eg treating doctor, employer, other service provider)

d. Are there additional strategies that would help the injured person achieve these goals? (workplace assessment,
independent assessment, RTW assistance)

8. Details of proposed plan Cost: 
Proposed number of sessions:
Proposed frequency of sessions: Cost: 
Time proposed for case conferencing/liaison: Cost: 
Proposed travel:
Anticipated discharge date: Practitioner’s name:
Total cost of plan: *Service provider no:
Fax:
9. Treating practitioner’s details
Practice name: Date:
Qualifications:
Phone:
Email:
Signature:

Injured person agreed to plan?  Yes  No

* This information is mandatory for Workcover claims

CC: Treating doctor

10. Insurer details:  Yes  No  Partial
 Yes  No  Partial
Date plan received:
Plan approved: Date:
Content acceptable but liability not determined:
Claims CM:

Signature:

Disclaimer
This publication may contain occupational health and safety and workers compensation information. It may include some of your obligations under the
various legislations that WorkCover NSW administers. To ensure you comply with your legal obligations you must refer to the appropriate legislation.
Information on the latest laws can be checked by visiting the NSW legislation website (www.legislation.nsw.gov.au).
This publication does not represent a comprehensive statement of the law as it applies to particular problems or to individuals or as a substitute for
legal advice. You should seek independent legal advice if you need assistance on the application of the law to your situation.
© WorkCover NSW

Catalogue No. WC02295  WorkCover Publications Hotline 1300 799 003
WorkCover NSW  92-100 Donnison Street Gosford NSW 2250
Locked Bag 2906 Lisarow NSW 2252  WorkCover Assistance Service 13 10 50
Website www.workcover.nsw.gov.au

ISBN 978 1 74218 299 5  © Copyright WorkCover NSW 0610

PSYCHOLOGICAL/COUNSELLING MANAGEMENT PLAN
EXPLANATORY NOTES

INTRODUCTION
The following notes provide information about how to complete the Psychological/Counselling Management plan.
The plan should be completed by the treating psychologist/counsellor, in agreement with the injured person*, where
psychological or counselling services are to be claimed under a Workcover or CTP (motor accident) claim.
Only services that meet the criteria for ‘reasonable and necessary’ under the Motor Accidents Compensation Act 1999
and ‘reasonably necessary’ under the Workers Compensation Act 1987 will be approved. Please refer to the MAA and
WorkCover Guidelines for more information including details of when to submit this plan.
The provider of psychological/counselling services is responsible for completing and signing the plan.
All sections of the plan must be completed to avoid delays in processing.

SECTION 1 – INJURED PERSON’S DETAILS
Include the name of the insurer case manager, the claim number and date of injury on the plan.

SECTION 2 – REASONS FOR REFERRAL
Describe the reason/s for the injured person’s referral for psychological treatment/counselling.

SECTION 3 – PRE-INJURY AND CURRENT FUNCTIONAL STATUS
a. Employment

• If at work, indicate number of pre-injury hours and number of hours currently working in pre-injury or suitable
duties.

• If not at work, indicate number of pre-injury hours and date last worked.
b. Other life roles

• If not employed at the time of injury, indicate the life role undertaken (eg student, homemaker, volunteer) and
briefly describe the activities involved.

c. Activities of daily living (ADL)
• Indicate self reported difficulties associated with activities of daily living such as self care, domestic or
household chores, community activities or transport.

d. Capacity to return to pre injury activity
• This includes work. Answer this in relation to the injured person’s psychological capacity.

* Workcover requires evidence that the nominated treating doctor agrees with the plan.

SECTION 4 – CLINICAL ASSESSMENT

Diagnosis

If a diagnosis is possible, indicate it here. The diagnosis must relate to the compensable injury and should utilise the
DSM-IV multiaxial classification where possible. If the diagnosis is different to that which is indicated on the medical
certificate, provide a brief explanation of the reasons for the difference.

SECTION 5 – BARRIERS TO RETURN TO PRE-INJURY DUTIES/ACTIVITY
Barriers
List any identified personal, medical, psychological and/or environmental barriers impacting on the injured person’s
ability to return to their pre-injury activities, including work. Consider factors such as personal, cultural, behavioural,
occupational and environmental factors. Barriers identified may not have immediate solutions and may include barriers
beyond those the treating provider can address in the treatment plan.

Define any issues that may complicate therapy, including motivation and issues which may affect participation.

Strategies to address barriers
Include your recommended or suggested strategies to address the barriers identified. Strategies may not necessarily be
a psychological intervention.

SECTION 6 – PROGRESS
Outline the goals of treatment to date, treatment strategies used and progress toward achieving the identified goals.

Outcome measures assist in measuring progress towards goals. Progress should always be defined using functional
(non-standardised) outcome measures. In some cases, standardised outcome measures may also be relevant.
Treatment practitioners should select measures that are most relevant to functional goals.

SECTION 7 – TREATMENT PLANNING
a. Goals

Goals should be specific, measurable, achievable, relevant and timely. (SMART)

S Specific What is to be achieved? Which problem is to be addressed? What treatment strategies are
M Measurable to be used?
A Achievable
R Relevant How will progress be objectively measured? How will achievements be recognised?
T Timed Include standardised tests if appropriate (eg DASS (Depression, Anxiety and Stress Scale).

Is achievement of the goal possible? What is the injured person’s ability to reach the goal?

The injured person should be motivated to work towards the goals. They should be
meaningful for the injured person.

The amount of time to achieve the goal should be reasonable.

Proposed treatment strategies
Outline treatment strategies, techniques and modalities to be used to achieve the identified treatment goals,
consistent with evidence based management of the injury.

b. Self management strategies
Detail strategies which the injured person has been taught and is successfully applying to independently manage
their psychological problem/s, including relapses.

c. Communication with other parties
List the names of parties that you have communicated with about the injured person’s treatment and return to
function and any other communication that may be necessary, although not provided by you.

d. Additional strategies
Document any other useful strategies which may be implemented by someone other than you. You may recommend
referral to another service as part of an overall management plan.

SECTION 8 – DETAILS OF PROPOSED PLAN
Provide details of services the insurer/agent is requested to fund:
• number and cost of sessions
• expected frequency of sessions
• anticipated time required for case conferencing with relevant parties (eg medical practitioner, rehabilitation provider,

other treating practitioners and the insurer/agent) and cost
• anticipated travel and cost
• anticipated discharge date
• total cost of the plan.

SECTION 9 – TREATING PRACTITIONER’S DETAILS:
Inclusion of the service provider number is mandatory for WorkCover claims.

Injured person agreed to plan?
Indicate that the injured person has been involved in the development of, and has agreed to, the plan.

Disclaimer
This publication may contain occupational health and safety and workers compensation information. It may include some of your obligations under the
various legislations that WorkCover NSW administers. To ensure you comply with your legal obligations you must refer to the appropriate legislation.
Information on the latest laws can be checked by visiting the NSW legislation website (www.legislation.nsw.gov.au).
This publication does not represent a comprehensive statement of the law as it applies to particular problems or to individuals or as a substitute for
legal advice. You should seek independent legal advice if you need assistance on the application of the law to your situation.
© WorkCover NSW

Catalogue No. WC02293  WorkCover Publications Hotline 1300 799 003
WorkCover NSW  92-100 Donnison Street Gosford NSW 2250
Locked Bag 2906 Lisarow NSW 2252  WorkCover Assistance Service 13 10 50
Website www.workcover.nsw.gov.au

ISBN 978 1 74218 297 1  © Copyright WorkCover NSW 0610

THIS IS A FILLABLE PDF FORM. CLICK IN THE FIRST FIELD TO START & USE THE TAB KEY TO MOVE FROM FIELD TO FIELD PRINT CLEAR

PSYCHOLOGICAL/COUNSELLING MANAGEMENT PLAN

Plan no: 1 Period: 18.10.09   to  30.12.09

1. Injured person’s details Insurer:
Claim no:
SAMPLEName: Joe Blog Insurer contact: The Insurance Company
20.10.66 ABC123456
DOB: Back Injury Referred by: Fred Bear
Date of referral:
Injury to which the 20.01.09 Date of initial Dr Smith
plan relates: Administration Officer assessment: 01.10.09
Date of injury: Date treatment 07.10.09
commenced:
Job title: 07.10.09

2. Reason for referral
Referral from nominated treating doctor requesting treatment for depression.

3. Pre-Injury & current functional status
a. Employment:

Hours 38 hours per week Current duties Administrative duties (typing, filing,
Pre-injury hours: Pre-injury/normal: answering phone)

Current hours: Not working Alternative/modified: N/A
Date last worked: 20.01.09
Not working: x

b. Other life roles (eg student, homemaker):
Father of 3 children, junior football coach (voluntary).

c. Outline any self reported difficulties with ADLs, or other functional activities.
Difficulties getting out of bed due to depression.
Difficulties planning daily activities.
Broken sleep - 3 hours/night.
Reduced socialisation with family members.
Frustration with persistent pain and restrictions.
d. In your opinion, does the injured person have the capacity to return to pre-injury activity?
Yes - but will also depend on physical capabilities.

4. Clinical assessment
Diagnosis (if applicable):M��il�d�D��e�p�re�s�s�io�n�.������������������������������������������������������������������

As diagnosed by nominated treating doctor.
Initial assessment findings are consistent with this diagnosis of Mild Adjustment Disorder with Depressive Mood.

5. Barriers to return to pre-injury duties/activity: Strategies to address barrier:
Support from employer.
Barrier: Support from workplace rehabilitation provider.
Doubts ability to return to pre-injury duties.

Concern work colleagues don’t understand, think he is As above.
“putting it on”.
SAMPLE
NTD continuing to certify unfit despite improved functional Discussion with Joe re: benefits of gradual RTW.
abilities and availability of suitable duties. Case conference to facilitate upgrade.

Child care responsibilities (aged 10 and 12) as wife returned Discussion with Joe re: alternative child care options.
to full time work.

Fear of re-injury. Challenge unhelpful beliefs.
Joe believes his depression and sleep problems are Education re: expectations of changes in pain and function.
compounding his ability to cope. Encourage regular exercise program.
Education re: nature of depression and importance of activity.
Introduce regular sleep hygiene program.

6. Progress
Outline treatment provided & progress made

Goals: Strategies used and progress made:
Increase hours of restful sleep to approx 6-8 hours per night. Sleep hygiene principles, regular sleep/wake time, and
stimulus control.
Still having trouble falling asleep due to rumination.
Using thought diary and sleep time cues.
Now sleeping continuously 4-5 hours.

Organise daily schedule with 1-2 hourly blocks of activities to Education provided about nature of depressive mood and its
increase pleasure level to at least 5/10 (originally 1/10). impact on motivation and inactivity.
Currently scheduling 50% of week and recording 5/10
pleasure level.

Develop understanding of mood management by daily Joe has learnt to track mood and is aware that increased daily
recording of high/low moods. activity increases his mood.
CBT used to challenge unhelpful thinking in particular
catastrophic and perfectionist thinking.
Continues to struggle with this.

Plan 1 x weekly family outing and engage wife and family in Joe has successfully planned these activities.
organising this.

7. Treatment planning
a. Proposed goals

Functional treatment goals (SMART): Proposed treatment strategies:

Increase hours of restful sleep to approx 6-8 hours per night. Promote use of thought diary and sleep time cues to self
Increase daily schedule with 1-2 hourly blocks of activities to manage sleep.
70% of week). Education provided about nature of depressive mood and its
impact on motivation and inactivity.
Monitor increase and benefits of activity.

Continue to develop understanding of mood management by CBT to challenge thinking.
daily recording of high/low moods.

Make contact with 3 friends and plan social contact with them. Provide additional education on scheduling and planning and
monitor this.
SAMPLE
Return to work on modified duties, for 4 hours, 5 days per Discuss with Joe perceived barriers of RTW.
week within 6 weeks. Engage other stakeholders to negotiate RTW via case
conferencing.

b. What self management strategies is the injured person successfully applying?

Self guided CBT resources - homework.

c. What other parties have you, or will you contact? (eg treating doctor, employer, other service provider)
Nominated treating doctor.
Physiotherapist.

d. Are there additional strategies that would help the injured person achieve these goals? (workplace assessment,
independent assessment, RTW assistance)

Possible referral to workplace rehabilitation provider to assist in return to work.

8. Details of proposed plan

Proposed number of sessions: Standard consultations x 6 Cost: $900

Proposed frequency of sessions: Weekly Cost: $300
Cost: N/A
Time proposed for case conferencing/liaison: 2 hours

Proposed travel: N/A

Anticipated discharge date: 30.12.09

Total cost of plan: $1200

9. Treating practitioner’s details Practitioner’s name: Sue Smith
Practice name: Smith Psychology *Service provider no: 99955555
Qualifications: Psychologist Fax: 123 456 789
Phone: 123 456 789
Email: [email protected] Date: 04.11.09
Signature: Sue Smith
No
Injured person agreed to plan?  ✓ Yes 

* This information is mandatory for Workcover claims

CC: Treating doctor

10. Insurer details:  Yes  No  Partial
 Yes  No  Partial
Date plan received:
Plan approved: Date:
Content acceptable but liability not determined:
Claims CM:

Signature:

SAMPLE
Disclaimer
This publication may contain occupational health and safety and workers compensation information. It may include some of your obligations under the
various legislations that WorkCover NSW administers. To ensure you comply with your legal obligations you must refer to the appropriate legislation.
Information on the latest laws can be checked by visiting the NSW legislation website (www.legislation.nsw.gov.au).
This publication does not represent a comprehensive statement of the law as it applies to particular problems or to individuals or as a substitute for
legal advice. You should seek independent legal advice if you need assistance on the application of the law to your situation.
© WorkCover NSW

Catalogue No. WC02327  WorkCover Publications Hotline 1300 799 003
WorkCover NSW  92-100 Donnison Street Gosford NSW 2250
Locked Bag 2906 Lisarow NSW 2252  WorkCover Assistance Service 13 10 50
Website www.workcover.nsw.gov.au

ISBN 978 1 74218 299 5  © Copyright WorkCover NSW 0610

APPENDIX 5: C ONDITIONS OF APPOINTMENT AS AN
INDEPENDENT CONSULTANT

Appointment as a WorkCover NSW approved Independent consultant is subject to the
following conditions:

1. Care. Injured Workers referred for assessment will be interviewed and examined with
the same care, consideration and courtesy, as are my own patients. I agree to accept
the standards set by my peers and respect community expectations in relation to the
conduct of independent consultants.

2. Independence. I understand that I am, and must appear to be, independent of the
Scheme Agent or self/specialised insurer. I will maintain my independent status in all
dealings with injured workers, other service providers and insurers. I also understand
that the insurer will explain the nature of my independent status to the worker prior to
the review.

3. Fairness. I will maintain a fair and reasonable approach to the review of treatment
by another practitioner. I will not criticise the treatment provided by any practitioner
associated with the review. I will discuss the findings and recommendations with the
injured worker in a fair and reasonable manner.

4. Commitment. I will assist in any way possible to resolve any difficulties or disagreements
that may become apparent in the course of the review or result from the review.

5. Understanding. I agree to remain mindful of the requirements of the Workplace Injury
Management and Workers Compensation Act 1998, and of any amendments to the Act.

6. No guarantee of work. I understand that whether my services are called upon will be
entirely at the discretion of Scheme Agents, self-insurers and specialised insurers.

7. Evaluation. I agree to participate in evaluation mechanisms in relation to all aspects
of conducting assessments and reviews. This will require that I retain all relevant
documentation associated with referral, assessments and reports, accounts and other
documents as WorkCover NSW may direct from time to time.

8. No conflict of interest. I agree not to recommend the referral of injured workers to any
business that I own or to which I provide treatment services. I agree to not treat any
injured worker whose treatment has been reviewed by me.

9. Withdrawal. I understand that I must give WorkCover NSW 14 days of my intention to
cease providing services as an Independent consultant. I understand that WorkCover may,
at its’ absolute discretion withdraw my appointment as an Independent consultant.

APPENDIX 6: A PPOINTED INDEPENDENT CONSULTANTS
FOR TREATMENT PROVIDERS

Mr Chris Allan Mr Thomas O’Neill
67 Campbell Street Level 5, Edgecliff Centre
Wollongong NSW 2520 203-233 New South Head Road
Phone: 02 4227 2363 Edgecliff NSW 2027
Email: [email protected] Phone: 02 9362 0386
Fax: 02 9362 0767
Also available in: Email: [email protected]
Parramatta
Sydney Also available in:
Wagga Wagga
Dr Terry Kohler Dubbo
15 Henry Kendall Street Richmond
West Gosford
NSW 2250
Phone: 02 4307 8146
Fax: 02 4324 9816
Email: [email protected]

Dr John McMahon
Sydney Clinical Psychology Centre
Suite 13-14, Level 4
229-231 Macquarie Street
Sydney NSW 2000
Phone: 1300 550 213
Fax: 02 9232 8118
Email: [email protected]

APPENDIX 7: PROCESS OF REVIEW BY INDEPENDENT CONSULTANTS

Insurer identifies a need for review regarding treatment. This will usually
be in relation to the number and/or frequency of consultations.

Insurer selects an independent consultant from WorkCover’s list
of approved consultants and forwards a referral including relevant
documentation (eg management plans, medical certificates and reports).
The referral will indicate the specific question(s) to be evaluated. The
insurer also forwards a letter to the treating psychologist/counsellor
informing them of the referral.

Independent consultant reviews the documentation.

Independent consultant supports Independent consultant identified issues/concerns
ongoing treatment and informs the and contacts the treating psychologist/counsellor
insurer of this. to discuss.

Both agree to the ongoing nature and frequency There is disagreement or uncertainty regarding the
of treatment, or to the cessation of treatment need for or the frequency of ongoing treatment.
after a defined period.
Independent consultant notifies the insurer of this
Independent consultant writes a report to the disagreement and nominates a date to assess the
insurer confirming that the proposed treatment or worker.
cessation of treatment has been agreed.
Insurer informs the worker that an assessment will
Ongoing treatment Treatment ceases and the be carried out and where and when this will occur.
continues. insurer may request an
assessment of the worker Independent consultant assesses the worker.
by the Independent
consultant. Independent consultant writes a report which
provides an opinion on the questions asked and
makes recommendations. Report forwarded by
consultant to treating treatment provider.

Insurer will consider the recommended changes
to not approve ongoing treatment or to approve
treatment provided liability for the claim is ongoing.

Worker agrees with changes to treatment Worker disagrees with changes to treatment

Worker refers the matter to the Commission

Catalogue No. WC02324  WorkCover Publications Hotline 1300 799 003

WorkCover NSW  92-100 Donnison Street Gosford NSW 2250
Locked Bag 2906 Lisarow NSW 2252  WorkCover Assistance Service 13 10 50
Website www.workcover.nsw.gov.au

ISBN 978 1 74218 322 0  © Copyright WorkCover NSW 0610