Psychologists working in the workers compensation system in Victoria (WorkSafe / WorkCover), Australia, are required to complete a Psychology Treatment Planning Form (PS604) near the commencement of treatment with a worker. This template aligns with that form and synthesises information from NovoNote and NovoPsych psychometrics, allowing clinicians to complete the PS604 form 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 PS604 form. For this reason, it is important to carefully review and double-check sections with such details for accuracy before transposing into your final PS604 form.
Psychology Treatment Planning Form (PS604)
Details
Worker’s Name:
Claim Number:
Occupation / Job Title:
General Practitioner’s Name:
Referrer’s Name:
Date of Referral:
Date of First Session:
1. Your DSM diagnosis (or provisional diagnosis) with respect to the claimable injury, using the latest published version of the DSM.
Describe the psychologist’s and / or General Practitioner’s diagnosis according to criteria set out in the Diagnostic and Statistical Manual of Mental Disorders – 5th Edition – Text Revision, including relevant diagnostic codes. Include the level of severity of any diagnosis, and any clinically significant co-morbidities.
2. With respect to the claimable injury, describe the psychological and physical symptoms the worker is currently presenting.
Describe the psychological and physical symptoms the client is currently experiencing in relation to their workplace injury.
3. Describe the impact of these symptoms on the following areas:
3.1 Home life.
Describe the impact of the client’s psychological and physical symptoms on their home life, including any issues with family, ability to perform domestic duties, or any other aspect of living at home. If applicable, refer to the client’s ability with these things prior to their workplace injury.
3.2 Social engagement.
Describe the impact of the client’s psychological and physical symptoms on their level of social engagement. If applicable, refer to the client’s level of social engagement prior to their workplace injury.
3.3 Emotional wellbeing / quality of life.
Describe the impact of the client’s psychological and physical symptoms on their emotional wellbeing and quality of life. Describe how the workplace injury has impacted on the client’s mental health. If applicable, refer to the client’s wellbeing and quality of life prior to their workplace injury.
3.4 Readiness to return to work or progress with the support of occupational rehabilitation services
3.5 Other
Describe the impact of the client’s psychological and physical symptoms on any other aspect of their lives not captured by 3.1, 3.2, 3.3, or 3.4. If applicable, refer to the client’s ability with these aspects prior to their workplace injury.
4. Details of any other psychological or physical conditions
5. Details of any factors that could enhance recovery (personal strengths or situational factors)
Describe any factors that could enhance the client’s recovery (e.g., personal strengths and characteristics, situational factors, family support, etc.).
6. Details of any factors that may impede recovery
7. Goals and treatment
7.1 Home life
7.2 Social engagement
7.3 Emotional wellbeing / quality of life
7.4 Developing work / training capacity
7.5 Other
8. Outcome measures – including individual goal attainment scales and validated psychometrics, results, and interpretation.
List the name, date of completion, results, and brief interpretation of psychometric testing undertaken by the client.
9. Anticipated treatment frequency and delivery mode
10. What else could help the worker with their recovery at this time?
Describe any other evidence-based suggestions that could help the client with their recovery in addition to other suggestions already made.
11. Which other clinicians have you, or will you, collaborate with to enhance the worker’s treatment and recovery?
List the professional disciplines, and names, of each individual that the psychologist will or may collaborate with to enhance the worker’s treatment and recovery from the workplace injury. This list should include health professionals that the psychologist has written to or received reports from.
12. Psychologist details
Name:
Address:
Provider Number:
Psychology Treatment Planning Form (PS604)
Details
Worker’s Name: Mary Blogs
Claim Number: WC2222-4444
Occupation / Job Title: Office Administrator
General Practitioner’s Name: Dr. Michael Moss
Referrer’s Name: Dr. Michael Moss
Date of Referral: 10th March 2025
Date of First Session: 18th March 2025
1. Your DSM diagnosis (or provisional diagnosis) with respect to the claimable injury, using the latest published version of the DSM.
Adjustment Disorder with Mixed Anxiety and Depressed Mood (309.28) – Moderate severity. This diagnosis is directly related to workplace bullying in January 2025.
2. With respect to the claimable injury, describe the psychological and physical symptoms the worker is currently presenting.
Mary presents with persistent anxiety, low mood, and concentration difficulties following workplace bullying. She experiences sleep disturbances, fatigue, headaches, and intrusive thoughts about the incident. Physical symptoms include muscle tension and gastrointestinal upset during stress.
3. Describe the impact of these symptoms on the following areas:
3.1 Home life.
Mary’s symptoms cause increased irritability affecting her relationship with her partner and difficulty maintaining household routines. Prior to the incident, Mary managed household responsibilities effectively.
3.2 Social engagement.
Mary has withdrawn from social activities and cancelled plans with friends multiple times since the workplace incident. She previously maintained an active social life and now fears discussing work-related stress. Mary reports feeling isolated and embarrassed about her current situation, leading to further social avoidance.
3.3 Emotional wellbeing / quality of life.
Mary’s emotional wellbeing has deteriorated significantly with frequent sadness, worry, and questioning of her professional competence. Prior to the incident, Mary described herself as generally optimistic and confident. She now experiences daily feelings of hopelessness and has lost interest in activities she previously enjoyed.
3.4 Readiness to return to work or progress with the support of occupational rehabilitation services
Mary is currently unfit for return to work due to anxiety symptoms that intensify when considering workplace attendance. Her concentration difficulties would impair work performance and she is not ready for occupational rehabilitation services.
3.5 Other.
Mary’s driving ability has been affected by concentration difficulties and anxiety, particularly near her workplace. She has reduced community involvement and cancelled her weekly exercise class.
4. Details of any other psychological or physical conditions.
Mary has no other significant psychological or physical conditions unrelated to the workplace injury.
Considerations for treatment and additional support.
No additional treatment required for other conditions at this time.
5. Details of any factors that could enhance recovery (personal strengths or situational factors).
Mary demonstrates strong motivation for recovery and good insight into her difficulties. She has a supportive partner, stable housing, and previous successful stress management experience.
6. Details of any factors that may impede recovery.
Ongoing workplace issues and uncertainty about return to work may impede recovery.
Considerations for treatment and additional support.
Workplace mediation services may assist with addressing ongoing workplace concerns.
7. Goals and treatment
7.1 Home life.
Mary aims to restore positive communication with her partner and resume household management routines. She specifically wants to reduce irritable outbursts and re-establish shared domestic responsibilities.
Treatment modality / interventions / strategies.
CBT techniques including stress management and communication skills training will be utilised.
7.2 Social engagement.
Mary wants to gradually resume social activities and rebuild confidence in social situations. She hopes to reconnect with her friendship network and overcome her current social anxiety.
Treatment modality / interventions / strategies.
Behavioural activation strategies and graded exposure to social situations will be implemented.
7.3 Emotional wellbeing / quality of life.
Mary seeks to reduce anxiety and depressive symptoms and restore her sense of personal competence. She aims to regain her previous optimistic outlook and enjoyment in daily activities.
Treatment modality / interventions / strategies.
CBT interventions targeting anxiety and depression will be the primary approach with cognitive restructuring techniques.
7.4 Developing work / training capacity.
Mary aims to develop confidence and coping strategies necessary for eventual return to work. She wants to manage work-related anxiety and rebuild her professional self-confidence.
Treatment modality / interventions / strategies.
Workplace-focused CBT interventions including anxiety management and assertiveness training will be provided.
7.5 Other.
Mary wants to restore her driving confidence and resume community activities. She aims to rebuild her overall sense of independence and capability in daily functioning.
Treatment modality / interventions / strategies.
Confidence-building exercises and graded exposure to previously avoided activities will be utilised.
8. Outcome measures – including individual goal attainment scales and validated psychometrics, results, and interpretation.
9. Anticipated treatment frequency and delivery mode
9.1 How many sessions do you anticipate are needed within the next 3-6 months?
Approximately 12-16 sessions are anticipated within the next 3-6 months.
9.2 What frequency?
Weekly sessions for initial 8 weeks, followed by fortnightly sessions.
9.3 Face to face or telehealth?
Treatment will be delivered via face-to-face sessions.
9.4 Provide a clinical rationale for the treatment frequency and modality?
Weekly sessions are indicated initially due to symptom severity and need for consistent support. Face-to-face delivery enhances therapeutic alliance and allows comprehensive assessment.
10. What else could help the worker with their recovery at this time?
11. Which other clinicians have you, or will you, collaborate with to enhance the worker’s treatment and recovery?
12. Psychologist details
Name: Sarah Smith
Address: 11 NovoNote Street, NovoPsych, Australia
Provider Number: 6543210A
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