Allied health clinicians working in the New South Wales workers compensation system in Australia are required to complete and submit an Allied Health Treatment Request (AHTR) to the insurer after a course of treatment has been provided, and before a new course of treatment can commence.
This template aligns with the AHTR form and synthesises information from NovoNote and NovoPsych that allows clinicians to complete the AHTR in a more expedited way.
Please note: This template may generate estimates for small numerical details—such as dates, the total number of consultations to date, and estimates of remaining sessions—based on the available information in the client’s documents and transcripts. That is, if this information has not been explicitly provided in a document, transcript, or contextual note, the template may make an estimate for some of the questions in the AHTR. For this reason, it is important to carefully review and double-check sections with such details for accuracy before transposing into your final AHTR form.
SIRA Allied Health Treatment Request
Request number:
Date of request:
Date services first commenced:
Total number of consultations to date:
Your allied health discipline:
Referred by:
Phone number:
Section 1: Injured person details
Name:
Date of birth:
Pre-injury occupation:
Pre-injury work hours / week (average):
Claim number:
Date of injury / accident:
Section 2: Your clinical assessment
Compensable injury illness
Describe the client’s workplace injury in one sentence.
Current clinical signs and symptoms
Describe the current psychological and physical symptoms the client is experiencing in relation to their workplace injury.
Risk screening
Have you applied a risk screening tool in your assessment
Print “Yes” if applied, “No” if not applied.
Name of risk screening tool
Print the name of the risk screening tool if applied (most suitable for judging suicide, self-harm, or violence risk).
Date administered
Print the date the assessment was administered.
Score / comment
Print the assessment score and provide brief interpretation.
Details of any pre-existing conditions directly relevant to the compensable injury
Describe any pre-existing conditions directly relevant to workplace injury.
Capacity
Do you have a copy of the position description / work duties
Print “Yes” if have copy, “No” if do not have copy.
Pre-injury capacity
Work
Describe what the client did before injury including occupation, tasks, duties, and work hours/days.
Usual activities
Describe pre-injury activities of daily living including driving, transport, leisure, self-grooming, domestic duties, social interaction.
Current capacity
Work
Describe current work capacity, what the client can do now, tasks they can perform, and current work hours/days.
Usual activities
Describe current capacity for activities of daily living.
Standardised Outcome Measures (SOM)
Interpretation of scores
Provide overall summary interpretation of all psychometric testing completed to date.
Section 3: Barriers to recovery and strategies to address
Barriers to recovery identified through your screening and assessment
Describe any factors or barriers impeding recovery.
Strategies to address barriers to recovery
Describe recommendations for treatment or additional support to address barriers including actions by clinician, client, and/or treating team.
Would you like any of the following assistance?
Direct contact from the insurer
Print “Yes” or “No”.
Case conference
Print “Yes” and describe who to have conference with, or “No”.
Collaborative case review with an independent consultant?
Print “Yes” or “No”.
Section 4: Treatment plan
Has the injured person achieved the goals from the last treatment plan?
Print “Yes”, “No”, “Partially”, or “N/A” for first request.
Injured person goals
Work goal
Describe specific, measurable, achievable, realistic, and timed work-related goal with target completion time.
Activity or participation goal
Describe specific, measurable, achievable, realistic, and timed activity/participation goal different from work goal with target completion time.
Injured person’s self-management
Describe techniques, strategies, activities, and exercises the client does between sessions, referencing evidence-based therapy.
Your intervention
Describe the evidence-based treatment approach.
Outline the rationale for the services you are requesting
Describe rationale for using this intervention to treat symptoms and presentation.
How many additional sessions do you anticipate before discharge?
Provide number of additional sessions needed.
Anticipated discharge date
Provide anticipated treatment end date.
If this date has changed since the last plan, please explain why
Describe why anticipated discharge date changed since last request.
Did you collaboratively develop this treatment plan with the injured person?
Print “Yes” or “No”.
If no, explain why
Provide explanation if treatment plan was not collaboratively developed.
Section 5: Service requested
Section 6: Your details
Treating practitioner name:
Practice email:
AHPRA number:
Best time/day to contact:
Practice name:
SIRA approval number:
Suburb:
State:
Postcode:
Treating practitioner email:
Phone number:
Fax number:
SIRA Allied Health Treatment Request
Request number: 3
Date of request: 22/05/2025
Date services first commenced: 15/03/2025
Total number of consultations to date: 8
Your allied health discipline: Clinical Psychologist
Referred by: Dr. Amanda Adam, NovoNote Health Solutions
Phone number: (02) 9876 5432
Section 1: Injured person details
Name: Mary Blogs
Date of birth: 15/08/1985
Pre-injury occupation: Administrative Coordinator
Pre-injury work hours / week (average): 38
Claim number: WC2025-4567
Date of injury / accident: 20/02/2025
Section 2: Your clinical assessment
Compensable injury illness
Mary sustained a psychological injury manifesting as adjustment disorder with anxiety and depressive symptoms following workplace bullying and harassment from her supervisor over a six-month period.
Current clinical signs and symptoms
Mary currently experiences persistent anxiety symptoms including panic attacks, sleep disturbance, and avoidance of work-related situations. She reports low mood, social withdrawal, and reduced confidence in her professional abilities. Physical symptoms include headaches, muscle tension, and gastrointestinal distress.
Risk screening
Have you applied a risk screening tool in your assessment: Yes
Name of risk screening tool: Depression Anxiety Stress Scales-21 (DASS-21)
Date administered: 20/05/2025
Score / comment: Depression: 18 (Moderate), Anxiety: 16 (Moderate), Stress: 20 (Moderate). Scores indicate clinically significant psychological distress across all domains.
Details of any pre-existing conditions directly relevant to the compensable injury
Mary has no documented pre-existing mental health conditions that would predispose her to developing psychological symptoms in the absence of workplace stressors.
Capacity
Do you have a copy of the position description / work duties Yes
Pre-injury capacity
Work. Mary worked full-time as an administrative coordinator managing client files, coordinating meetings, and supervising junior staff. She worked 38 hours per week across five days with excellent performance reviews.
Usual activities. Mary independently managed all activities of daily living including driving, household tasks, social activities, and regular exercise. She maintained active social relationships and engaged in community volunteer work.
Current capacity
Work. Mary currently has no capacity for work in her pre-injury role due to severe anxiety about workplace interactions and avoidance of her former workplace. She may have limited capacity for alternative work arrangements in a different environment with appropriate supports.
Usual activities. Mary can manage basic self-care and household tasks but has reduced capacity for social activities and community engagement. She experiences difficulty driving to unfamiliar locations and has ceased volunteer activities.
Standardised Outcome Measures (SOM)
Interpretation of scores
Mary has shown consistent improvement across all DASS-21 domains since commencing treatment, with scores reducing from severe to moderate range. This indicates positive response to therapeutic intervention, though symptoms remain clinically significant.
Section 3: Barriers to recovery and strategies to address
Barriers to recovery identified through your screening and assessment
Mary’s recovery is impeded by ongoing workplace investigation processes creating uncertainty about her employment future. Financial stress due to reduced income is contributing to anxiety and limiting her engagement in social activities.
Strategies to address barriers to recovery
Liaison with workplace rehabilitation coordinator to clarify return-to-work options and timeline. Referral to financial counselling services to address immediate financial concerns and explore income support options during recovery period.
Would you like any of the following assistance?
Direct contact from the insurer No
Case conference Yes – with workplace rehabilitation coordinator and treating GP
Collaborative case review with an independent consultant? No
Section 4: Treatment plan
Has the injured person achieved the goals from the last treatment plan? Partially
Injured person goals
Work goal
Mary will develop confidence to engage in structured return-to-work planning discussions by completing anxiety management techniques and workplace-focused exposure exercises. Target completion within 4 weeks.
Activity or participation goal
Mary will resume one regular social activity (weekly coffee with friend) by implementing anxiety management strategies and graded exposure to social situations. Target completion within 3 weeks.
Injured person’s self-management
Mary practices daily relaxation techniques including progressive muscle relaxation and mindfulness exercises. She maintains a mood diary to track anxiety triggers and implements cognitive restructuring techniques learned in therapy. Mary engages in regular walking for physical activity and stress management.
Your intervention
Treatment utilises trauma-informed cognitive behavioural therapy focusing on anxiety management, cognitive restructuring, and graded exposure to workplace-related situations.
Outline the rationale for the services you are requesting
CBT is evidenced-based treatment for adjustment disorders and workplace-related psychological injuries. Continued therapy is required to consolidate coping skills and support return-to-work planning.
How many additional sessions do you anticipate before discharge? 6
Anticipated discharge date 15/07/2025
If this date has changed since the last plan, please explain why. Discharge date extended by 3 weeks due to slower than expected progress with workplace anxiety and need for additional return-to-work preparation.
Did you collaboratively develop this treatment plan with the injured person? Yes
If no, explain why N/A
Section 5: Service requested
Section 6: Your details
Treating practitioner name: Dr. Sarah Smith
Practice email: admin@novopsych.com.au
AHPRA number: PSY0001111
Best time/day to contact: Monday to Friday, 9:00 AM to 5:00 PM
Practice name: NovoPsych Psychology Services
SIRA approval number: SP12345
Suburb: NovoPsych
State: NSW
Postcode: 2000
Treating practitioner email: s.smith@novopsych.com.au
Phone number: (02) 1234 5678
Fax: (02) 1234 5679
Share
See how mental health professionals have transformed their practice with NovoNote.
