Psychologists working in the WorkSafe Victoria workers compensation system in Australia (WorkSafe / WorkCover) are advised to complete a Psychology Treatment Review Form (PS109) after ten sessions or six months of treatment (whichever comes first). This template aligns with that form and synthesises information from NovoNote and NovoPsych psychometrics, allowing clinicians to complete the PS109 form in a more expedited way. This template will produce more accurate results when a Psychology Treatment PLANNING Form (PS604) has already been produced, as this template can incorporate and build on data previously entered in the PS604 form.
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 PS109 form. For this reason, it is important to carefully review and double-check sections with such details for accuracy before transposing into your final PS109 form.
Psychology Treatment Review Form (PS109)
Details
Worker’s Name:
Claim Number:
Occupation / Job Title:
General Practitioner’s Name:
Referrer’s Name:
Date of Referral:
Number of sessions to date:
Referring to the Psychology treatment planning form, please review the progress and the ongoing recommendations.
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. Describe if the diagnosis has changed since completion of the original Psychology Treatment Planning Form.
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. Describe if there have been any changes since completion of the original Psychology Treatment Planning Form.
3. With respect to the claimable injury, what changes have occurred to the following, in comparison to the Psychology treatment planning form:
3.1 Home life.
Describe any changes that have occurred since completion of the original Psychology Treatment Planning Form in relation to the impact of the client’s psychological and physical symptoms on their home life.
3.2 Social engagement.
Describe any changes that have occurred since completion of the original Psychology Treatment Planning Form in relation to the impact of the client’s psychological and physical symptoms on their level of social engagement.
3.3 Emotional wellbeing / quality of life.
Describe any changes that have occurred since completion of the original Psychology Treatment Planning Form in relation to the impact of the client’s psychological and physical symptoms on their emotional wellbeing and quality of life.
3.4 Readiness to return to work or progress with the support of occupational rehabilitation services.
Describe any changes that have occurred since completion of the original Psychology Treatment Planning Form in relation to the impact of the client’s psychological and physical symptoms on the client’s readiness to return to work or progress with occupational rehabilitation services. Make an explicit statement about the client’s current capacity to engage in employment or occupational rehabilitation services.
3.5 Other areas.
Describe any changes that have occurred since completion of the original Psychology Treatment Planning Form in relation to 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 above.
4. Goals – refer to goals identified on the Psychology treatment planning form
List the goals that the client had identified in the Psychology Treatment Planning Form. State the progress with each goal using one of five descriptors: “Setback experienced”; “No progress”; “Progressing towards goal”; “Goal achieved; or “Exceeded goal expectations”. Then, provide a comment about the client’s progress, barriers to progress, and future expectations.
5. Outcome measures – including individual goal attainment scales and validated psychometrics, results, and interpretation.
5.1 Previous scales, results and interpretation from the Psychology treatment planning form
List the name, date of completion, results, and brief interpretation of psychometric testing undertaken by the client, as listed on the Psychology Treatment Planning Form.
5.2 Follow-up results
List the name, date of completion, results, and brief interpretation of psychometric testing undertaken by the client since the Psychology Treatment Planning Form.
6. Factors that are impeding recovery
Describe any factors that are impeding the client’s recovery.
How may these be addressed?
Describe any recommendations for potential treatment or additional support that may assist the client in managing any factors impeding their recovery.
7. Details of factors that are improving recovery (personal strengths or situational factors)
Describe any factors that are enhancing the client’s recovery.
8. What else would 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.
9. Treatment
9.1 How many sessions have you provided?
Describe how many sessions the psychologist has had in total with the client and the timeframe within which those sessions have taken place.
9.2 How many sessions do you anticipate will be required over the next 6-12 months and at what frequency?
Describe how many sessions the psychologist anticipates will be required over the next six to twelve months and at what frequency.
9.3 What is your clinical rationale for the treatment frequency?
Describe the psychologist’s rationale for the suggested frequency of sessions required to assist the client in recovering from the workplace injury.
10. 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 has collaborated with, or may collaborate with in the future, to enhance the worker’s treatment and recovery from the workplace injury.
11. Psychologist details
Name:
Address:
Provider Number:
Psychology Treatment Review Form (PS109)
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
Number of sessions to date: 8 sessions
Referring to the Psychology treatment planning form, please review the progress and the ongoing recommendations.
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) – Mild to Moderate severity. The diagnosis remains unchanged since the original Psychology Treatment Planning Form, however the severity has reduced from moderate to mild-moderate as symptoms have improved with treatment.
2. With respect to the claimable injury, describe the psychological and physical symptoms the worker is currently presenting.
Mary currently presents with reduced anxiety and depressive symptoms compared to initial presentation. She experiences occasional worry about workplace situations and mild concentration difficulties, though these are significantly improved. Physical symptoms of muscle tension and sleep disturbances have decreased considerably with treatment.
3. With respect to the claimable injury, what changes have occurred to the following, in comparison to the Psychology treatment planning form:
3.1 Home life.
Mary has shown significant improvement in her home life with reduced irritability and improved communication with her partner. She has successfully resumed most household management tasks and reports feeling more emotionally available for her relationship.
3.2 Social engagement.
Mary has gradually re-engaged with social activities, attending two social gatherings in the past month after months of complete avoidance. She reports feeling more confident in social situations and has reduced her tendency to cancel plans with friends.
3.3 Emotional wellbeing / quality of life.
Mary’s emotional wellbeing has improved substantially with reduced daily feelings of sadness and worry. She reports renewed interest in activities she previously enjoyed and describes feeling more optimistic about her future.
3.4 Readiness to return to work or progress with the support of occupational rehabilitation services.
Mary has progressed significantly in her readiness to return to work, moving from completely unfit to expressing willingness to discuss graduated return options. She now feels capable of engaging with occupational rehabilitation services and has agreed to attend initial consultations.
3.5 Other areas.
Mary’s driving confidence has improved and she now travels independently to therapy sessions and local destinations. She has resumed her weekly exercise class and reports feeling more capable in daily functioning tasks.
4. Goals
5. Outcome measures
5.1 Previous scales, results and interpretation from the Psychology treatment planning form
5.2 Follow-up results
6. Factors that are impeding recovery
Ongoing uncertainty about workplace dynamics and lack of resolution regarding the original bullying incident continue to create some anxiety about return to work. Mary reports occasional setbacks when reminded of the workplace situation.
How may these be addressed?
Workplace mediation services and clear return-to-work planning with occupational rehabilitation support could address remaining workplace concerns. Continued psychological support during transition back to work will be beneficial.
7. Details of factors that are improving recovery (personal strengths or situational factors)
8. What else would help the worker with their recovery at this time?
9. Treatment
9.1 How many sessions have you provided?
I have provided 8 sessions with Mary over a 10-week period from 18th March 2025 to 15th May 2025.
9.2 How many sessions do you anticipate will be required over the next 6-12 months and at what frequency?
I anticipate 6-8 additional sessions over the next 6 months at fortnightly intervals, reducing to monthly sessions as Mary transitions back to work.
9.3 What is your clinical rationale for the treatment frequency?
Reduced frequency is appropriate given Mary’s significant symptom improvement and increased coping capacity. Ongoing support during work transition will help maintain gains and address any emerging challenges during the return-to-work process.
10. Which other clinicians have you, or will you, collaborate with to enhance the worker’s treatment and recovery?
11. Psychologist details
Name: Sarah Smith
Address: 11 NovoNote Street, NovoPsych, Australia
Provider Number: 2587410A
Share
See how mental health professionals have transformed their practice with NovoNote.
