Rehabilitation Plan
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 Defence Force, members of the Australian Federal Police and their dependants.
DVA may obtain medical/psychological and rehabilitation information and use such information as necessary to determine how to best manage your case and/or entitlement to benefits.
To read more visit http://www.dva.gov.au/site-information/privacy/privacy-notice-%E2%80%93-financial-and-health-information.
Plan number:
(numbered in consecutive order)
Client Details
Full name:
Date of birth:
Defcare Case ID:
Compensable Conditions:
Medical Restrictions:
Referral Date:
Plan Start Date:
(the sign off date for approval given to commence plan)
Anticipated Plan End Date:
Is the focus of this plan return to work or non-return to work?
Return to work
Non-return to work
For assistance phone DVA on 133 254 (metropolitan callers) or 1800 555 254 (regional callers).
Client Name: ___________________________ Defcare Case ID: _____________________________
Rehabilitation Plan - D1347
Page 1 of 8
Goal Attainment Scaling
Goal Attainment Scaling involves the rehabilitation provider and client working together to develop individualised goals for the Rehabilitation Plan and defining
the expected outcome for each goal. The expected outcome is one that the client and rehabilitation provider believe are realistically achievable by the end of their
Rehabilitation Program. Please refer to Goal Attainment Scaling in CLIK for further information.
Goal 1:
To be achieved within (indicate timeframe):
Category (Psychosocial, Medical Management, Vocational):
Describe all of the following Outcomes Most unfavourable outcome (-2):
Less than expected outcome (-1):
Expected outcome (0):
More than expected outcome (+1):
Most favourable outcome (+2):
Activities to achieve goal:
Importance of goal for client:
Challenge in achieving goal:
Parties involved:
A little
A little
Moderately
Moderately
For assistance phone DVA on 133 254 (metropolitan callers) or 1800 555 254 (regional callers).
Client Name: ___________________________ Defcare Case ID: _____________________________
Rehabilitation Plan - D1347
Start date:
End date:
Very
Very
Page 2 of 8
Goal 2:
To be achieved within (indicate timeframe):
Category (Psychosocial, Medical Management, Vocational):
Describe all of the following Outcomes Most unfavourable outcome (-2):
Less than expected outcome (-1):
Expected outcome (0):
More than expected outcome (+1):
Most favourable outcome (+2):
Activities to achieve goal:
Importance of goal for client:
Challenge in achieving goal:
Parties involved:
A little
A little
Moderately
Moderately
For assistance phone DVA on 133 254 (metropolitan callers) or 1800 555 254 (regional callers).
Client Name: ___________________________ Defcare Case ID: _____________________________
Rehabilitation Plan - D1347
Start date:
End date:
Very
Very
Page 3 of 8
Goal 3:
To be achieved within (indicate timeframe):
Category (Psychosocial, Medical Management, Vocational):
Describe all of the following Outcomes Most unfavourable outcome (-2):
Less than expected outcome (-1):
Expected outcome (0):
More than expected outcome (+1):
Most favourable outcome (+2):
Activities to achieve goal:
Importance of goal for client:
Challenge in achieving goal:
Parties involved:
A little
A little
Moderately
Moderately
For assistance phone DVA on 133 254 (metropolitan callers) or 1800 555 254 (regional callers).
Client Name: ___________________________ Defcare Case ID: _____________________________
Rehabilitation Plan - D1347
Start date:
End date:
Very
Very
Page 4 of 8
Goal 4:
To be achieved within (indicate timeframe):
Category (Psychosocial, Medical Management, Vocational):
Describe all of the following Outcomes Most unfavourable outcome (-2):
Less than expected outcome (-1):
Expected outcome (0):
More than expected outcome (+1):
Most favourable outcome (+2):
Activities to achieve goal:
Importance of goal for client:
Challenge in achieving goal:
Parties involved:
A little
A little
Moderately
Moderately
For assistance phone DVA on 133 254 (metropolitan callers) or 1800 555 254 (regional callers).
Client Name: ___________________________ Defcare Case ID: _____________________________
Rehabilitation Plan - D1347
Start date:
End date:
Very
Very
Page 5 of 8
Sign-Off and Distribution
Client
Rehabilitation provider
I have been involved in the development of this Rehabilitation Plan. I agree to participate in this agreed plan and understand my rights and obligations under the
following legislation (tick the appropriate legislation box):
Veterans’ Entitlements Act 1986
Safety, Rehabilitation & Compensation Act 1988
Military Rehabilitation & Compensation ACT 2004
Name:
DVA File Number:
Signature:
Date:
Name:
I agree to provide the above Rehabilitation Program outlined to the above person.
Date:
Signature:
Rehabilitation coordinator
(delegate)
Tick the appropriate Commission box.
Delegate of the Repatriation Commission
Delegate of the Military Rehabilitation and Compensation Commission
Name:
Telephone: [
Fax: [ ]
]
I hereby determine under the provision identified below, that the client named in page 1 should undertake the rehabilitation program
described in this Rehabilitation Plan. I agree to distribute copies of this Rehabilitation Plan to all relevant parties. (tick the appropriate
legislation box).
Instrument No.11 of 2015, Veterans’ Entitlements Act 1986
Section 37, Safety, Rehabilitation & Compensation Act 1988
Section 51, Military, Rehabilitation & Compensation Act 2004
Signature:
Date:
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 Plan - D1347
Page 6 of 8
This page is intentionally blank
For assistance phone DVA on 133 254 (metropolitan callers) or 1800 555 254 (regional callers).
Client Name: ___________________________ Defcare Case ID: _____________________________
Rehabilitation Plan - D1347
Page 7 of 8
Rehabilitation Plan Costs
Do not provide this page to client.
Rehabilitation Plan Costs
Goal Number:
Activity:
Provider costs: $
Name:
Signature:
DVA rehabilitation co-ordinator
(d)elegate
TOTAL Costs: $
$
TOTAL PLAN COSTS
Rehabilitation provider
Third Party costs: $
Date:
Name:
Signature:
For assistance phone DVA on 133 254 (metropolitan callers) or 1800 555 254 (regional callers).
Client Name: ___________________________ Defcare Case ID: _____________________________
Rehabilitation Plan - D1347
Date:
Page 8 of 8