DVA Patient Care Plan

DVA Client Details

Name: James Brown

DOB: 14/03/1985

DVA file number: N1234567

Phone: 0412 345 678

Referring clinician: Dr Novo Note, General Practitioner

Referral date for this cycle: 03/02/2026

Previous treatment: Initial consultation 15/01/2024; previous treatment cycle completed 20/01/2025

Has the client consented to this Patient Care Plan? Yes

Allied Health Provider Details

Name and provider number: Dr Sarah Green, provider number 2345678A

Allied health profession: Clinical Psychologist

Practice name and address: NovoPsych Psychology Practice, 11 NovoNote Street, NovoPsych, Australia

Phone: (03) 9000 0000

Fax: (03) 9000 0001

Provider signature: To be signed by provider.

Date: 24/09/2026

Condition(s) Being Managed / Reason(s) for Referral

James is being treated for Post-Traumatic Stress Disorder and Major Depressive Disorder related to his military service. Since completing his first treatment cycle, he has continued to experience intrusive memories and hypervigilance, alongside low mood and reduced motivation.

Client Goals

Goals have been set and agreed to with the client: Yes

Goals:

1. Use a grounding strategy independently when experiencing intrusive memories, on most occasions, within 8 weeks.
2. Attend a community walking group for at least 30 minutes twice weekly, within 3 months.
3. Reduce avoidance of driving on the freeway to enable attendance at appointments independently, within 6 months.

Proposed Management Plan

Treatment modality: Trauma-focused Cognitive Behaviour Therapy incorporating exposure-based techniques, combined with behavioural activation for depressive symptoms.

Type, number and frequency of services: 12 individual sessions, fortnightly, face-to-face.

Provider role: Deliver trauma-focused CBT sessions, monitor symptom progress using validated outcome measures, and support James in developing and practising coping strategies.

Client role: Practise grounding strategies daily and complete between-session behavioural activation tasks as agreed.

Aids or appliances required: None required.

Expected outcomes: Reduced frequency and intensity of intrusive memories, improved mood, and increased engagement in social and occupational activities.

Proposed timelines: Review at session 6 (approximately 3 months) and at completion of the cycle (approximately 6 months).

Outcome Measures

1. Measure: Kessler Psychological Distress Scale (K10); Initial assessment score: 34 (Very high) (Date: 15/01/2024); Start of this cycle score: 27 (High) (Date: 03/02/2026)
2. Measure: PTSD Checklist for DSM-5 (PCL-5); Initial assessment score: 58 (Date: 15/01/2024); Start of this cycle score: 44 (Date: 03/02/2026)

Interpretation of outcome measures: At initial assessment, James’s K10 score indicated very high psychological distress and his PCL-5 score was above the clinical cut-off, consistent with probable PTSD. At the start of this cycle, both scores had reduced, indicating a decrease in psychological distress and PTSD symptom severity, though both remain in a clinically significant range.

Additional comments: James has maintained regular attendance and has expressed motivation to continue treatment into this cycle.