ACC Specialist Cover Assessment Report (ACC8536)
Part A: Kiritaki Information
1. Kiritaki Details
- Kiritaki’s full name:
- Date of birth:
- ACC claim number:
- Contact details and safe contact information:
Part B: Specialist Cover Assessment
2. Sources of Information
- List each consultation, including date and duration.
- List all sources of information reviewed, including dates and authors where documented.
3. About the Schedule 3 Events
- For each event, describe the specific acts, date or date range, frequency, and the perpetrator’s relationship to the kiritaki.
- If sufficient detail exists in reviewed Sensitive Claims Service reports, state this and adopt that information.
4. Background Kiritaki Information
- a. Background summary: Summarise relevant medical, cultural, family/whānau, developmental, education, employment, alcohol and drug, and forensic history.
- b. Current circumstances and presenting difficulties:
- Current circumstances: Describe living situation, relational circumstances, occupational status, social circumstances, and finances.
- Presenting difficulties: Describe current emotional, cognitive, behavioural, relational, and functional difficulties.
- c. Mental health history and treatment delivered:
- Mental health history: Summarise past and current mental health history, including diagnoses, episodes, and clinical contacts.
- Treatment delivered: Summarise psychological and other treatments received, historically and currently.
- d. Other treating health providers: List each provider, including contact name and email or phone.
- e. Current medications and dosages: List all medications, dosages, and prescriber names.
5. Strengths and Vulnerabilities
- a. Personality assessment: Describe personality patterns relevant to strength, vulnerability, and formulation.
- b. Kiritaki strengths and protective factors: Describe factors likely to support recovery.
- c. Areas of vulnerability: Describe factors that may affect the kiritaki’s ability to engage in or benefit from treatment.
- d. Risk: State whether risk is present; if yes, describe risk to self, risk to others, and risk of harm from others, and note any duty of care actions taken.
- e. Other agencies: State whether other agencies are involved; if yes, list each.
6. Psychometrics
- For each measure, print the name, date administered, respondent, and score or clinical classification.
- Describe the overall interpretation, noting significant findings, consistency or discrepancy across measures, and relevance to the formulation.
7. Clinical Symptoms or Diagnosis
- 1. Diagnosis: State each diagnosis with the full name, diagnostic system, code, and severity level; explain how criteria are met with reference to documented symptoms — include all diagnoses, not only those proposed as mental injuries.
- 2. Significant difficulties: Describe clinically significant difficulties that do not meet full diagnostic threshold.
- Formulation and summary: Provide a clinical formulation integrating background, Schedule 3 events, vulnerabilities, protective factors, and current presentation.
8. Opinion on Mental Injury
- a. Causal relationship — Schedule 3 events: Describe the clinical evidence for a causal relationship between the Schedule 3 events and the proposed mental injuries, presented as clinical opinion.
- b. Causal relationship — other life factors: Describe the contribution of other documented life factors to the proposed mental injuries.
- Date mental injury suffered: For each proposed mental injury, state the diagnosis and the estimated date it reached diagnostic threshold.
- Clinical rationale for dates: Summarise the clinical reasoning and evidence base for each date stated.
9. Treatment
- Outline evidence-based treatment recommendations for the proposed mental injuries, including modalities and relevant ACC Sensitive Claims Service options.
- Describe recommendations for non-injury difficulties, including non-ACC services where relevant.
10. Prognosis
- Describe the likely trajectory of recovery with appropriate treatment.
- Note potential barriers to recovery.
Part C: Function Assessment
Include only if ACC has given prior approval for a Function Assessment.
11. Current and Ongoing Functional Effects
- a. Describe the symptoms of the proposed or covered mental injuries.
- b. Describe the effects on daily functioning, including examples.
- c. Describe any effects on work capacity not already covered.
- d. Identify any safety concerns that may constitute a barrier to work.
- e. Describe comorbid conditions affecting functioning or work capacity.
- f. State whether the proposed or covered mental injuries are materially contributing to the functional impact.
- g. Describe the impact on any specific work types identified in the referral.
- h. Summarise recommendations to support return to work.
12. Effects on Past Functioning
- Describe functional effects that were likely a barrier to work in the past, including dates and the reasons work capacity was affected.
Part D: Other Information and Declarations
13. Other Information
- Date of last face-to-face meeting with the kiritaki.
- Date of disengagement, if applicable.
- Any other relevant information.
- List of attached documents.
- Other providers who contributed to the assessment, with contact details.
14. Provider Declaration
- List each declaration checkbox for the clinician to confirm with the kiritaki prior to submission.
- State whether the kiritaki participated in the feedback session; if not, provide the reason.
- Print provider name and profession, Provider ID, Supplier name, Supplier ID, and date.
