Rehabilitation
Assessment Report
Privacy Notice
Your personal information is protected by law, including the Privacy Act 1988. Your personal information may be
collected by the Department of Veterans’ Affairs (DVA) for the delivery of government programs for war veterans,
members of the Australian Defense Force, members of the Australian Federal Police and their dependants.
To read more visit http://www.dva.gov.au/site-information/privacy/privacy-notice-%E2%80%93-financial-andhealth-information.
Client Details
Full name:
Date of birth:
Defcare Case ID:
Address:
Telephone numbers:
Home: [ ]
Work: [ ]
Mobile: [ ]
Email:
Emergency contact:
Name:
Phone number: [ ]
Compensable condition(s):
Non-compensable condition(s):
Current work (paid or voluntary):
Discharge date from the Defence Force:
Discharge type:
Medical discharge
Non-medical discharge
For assistance phone DVA on 133 254 (metropolitan callers) or 1800 555 254 (regional callers).
Client Name: ___________________________ Defcare Case ID: _____________________________
Rehabilitation Assessment Report - D1334
Page 1 of 4
Assessment Details
Purpose of report:
To determine the client’s capacity to undertake rehabilitation and where required recommend appropriate
rehabilitation interventions and actions.
Client presentation: (at the time of the assessment)
Physical appearance, concentration, general manner, communication, behaviors, insight and
understanding of reality.
Client expectations:
Client’s expectations, level of understanding of the rehabilitation process and their motivations, agenda(s)
and coping strategies.
Medical history: (including physical and mental health conditions)
Impact of current condition(s) both compensable and non-compensable conditions and date and cause of
injury (workplace/sport/trauma), relevant historical and current interventions (including medications),
prognosis, stability of conditions, and side-effects of conditions.
Current psychological status:
Lifestyle changes, coping strategies and adjustment to injury. Self-esteem and confidence, ability to
communicate, engagement with family, friends and broader community.
Please attach relevant reports if available and applicable.
Home routines, tasks & self care: (including Activities of Daily Living – ADL)
Accommodation arrangement, family circumstances, support from friends and community, daily routine,
responsibilities, home activities and self-care needs. Who did home routine activities prior to injury?
Aids, appliances or modifications to home, workplace or vehicle:
Mobility, driving ability and capacity to access public transport and the community. Aids/appliances to
promote independence and quality of life. Provide supporting information. Clearly identify immediate or
urgent needs and need for further assessments in the final recommendation section.
Recreation, leisure and community activities:
Social, cultural and spiritual circumstances. Sporting, hobbies, leisure interests and engagement with the
local community.
Rest and sleep:
Sleeping pattern and capacity to rest/revive.
Vocational/training status:
Overview of education, qualifications, skills, affiliations, licenses, transferrable employment skills, work
summary and current studies. Career interests and goals, geographical and labor market issues. Income
summary including normal weekly earnings and compensation payments. Positive indicators and barriers
to return to work and training.
For assistance phone DVA on 133 254 (metropolitan callers) or 1800 555 254 (regional callers).
Client Name: ___________________________ Defcare Case ID: _____________________________
Rehabilitation Assessment Report - D1334
Page 2 of 4
Past or current rehabilitation interventions or actions taken:
Outcomes of status of rehabilitation (medical management, vocational and/or psychosocial) activities the
client has undertaken or is intending to undertake (including ADF, DVA and community/civilian). Details
and status of compensation matters.
Client’s capability, attitude and identified barriers to rehabilitation:
The key issues for the client’s rehabilitation in their home, work, community or recreational environments.
Overall opinion and comments regarding the client’s assessed capability for, and strengths and barriers to
medical management, vocational and/or psychosocial rehabilitation.
Life Satisfaction Indicators (LSI)
A measure of personal satisfaction with different aspects of life, to be collected from each client at the start
of each rehabilitation assessment period, at 6-monthly intervals until a plan is closed and finally at plan
closure. Please refer to Goal Attainment Scaling in CLIK for information regarding the LSI.
Date LSI form completed:
Average satisfaction with life score :
(sum of the total life score divided by 10)
Average satisfaction with job score:
(sum of the total job score divided by 6)
Does the client score an indicator less than 6?
Indicators can be used to inform the creation of goals.
Yes
No
If YES, provide comment:
Recommendations:
As a result of the investigations and observations made, please address the following appropriate
Act under which the client has entitlements (VEA, SRCA or MRCA). URGENT MATTERS WHICH
REQUIRE IMMEDIATE ATTENTION. Does the client have the capacity to undertake a whole-ofperson rehabilitation program? What type of rehabilitation program is being proposed? If no
program is proposed, please provide a clear rationale and reasons. If a rehabilitation program is
being proposed, outline goals, specific objectives for each goal, and estimated duration of the
proposed program.
For assistance phone DVA on 133 254 (metropolitan callers) or 1800 555 254 (regional callers).
Client Name: ___________________________ Defcare Case ID: _____________________________
Rehabilitation Assessment Report - D1334
Page 3 of 4
Sign-off and Distribution
Provider name:
Signature:
Date:
Name of Rehabilitation Agency:
Address:
Telephone number: [ ]
Mobile number: [ ]
Email:
Providers scan and email PDF to:
South Australia/Victoria
rcg.adelaide.rehab@dva.gov.au
Northern Territory/Tasmania/Western Australia
rcgperthrehab@dva.gov.au
Queensland
RnC.Brisbane.Rehab@dva.gov.au
Queensland (northern QLD)
rcg.townsville@dva.gov.au
New South Wales/ACT
NSWACT.Rehab@dva.gov.au
For assistance phone DVA on 133 254 (metropolitan callers) or 1800 555 254 (regional callers).
Client Name: ___________________________ Defcare Case ID: _____________________________
Rehabilitation Assessment Report - D1334
Page 4 of 4