/ Rehabilitation Closure Report
Client Details
Full name:
Date of birth:
Defcare Case ID:

Plan Details

Referral date:
Plan start date:
Plan closure date:
Reasons for closure:
(please indicate in the boxes below why the RehabilitationPlan is closing)
Plan completed
Changing provider
Moving interstate
Unable to contact client
Client medically unfit
Client refused to participate
Client deceased
Plan has changed between RTW goals and NRTW goals
Successful return to work
Coordinator please complete the below incapacity information if required
Incapacity benefits ceased (indicate below why this occurred)
Non-compliance
Able to earn
Other ______
Work Status of Client at Plan Closure
(Remove if this plan did not include a vocational goal)
Work type:
Same
Notemployed
New (please give details below)
Duties:
Same
Modified (please give details below)
New (please give details below)
Hours:
Same
Modified
New (please give details below)
Casual hours: Permanent hours:
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, at 6-monthly intervals until a plan is closed and finally at plan closure. The provider must complete this section, to the best of their knowledge, if the client is uncontactable. Please refer to Goal Attainment Scaling in CLIK for information regarding the LSI.
Date LSI form completed:
LSI completed by: Client or Provider (delete the incorrect option)
Score at Rehabilitation Assessment / Score at Rehabilitation Progress Report / Score at Closure Report
Average Satisfaction with lifescore:(sum of the total score divided by 10)
Average satisfaction with jobscore:
(sum of the total score divided by 6)
Goal Attainment Scaling
Goal 1:
Goal Completion Date:
Goal Attainment Scaling score (Score from -2 to +2. Refer to Goal Attainment Scaling in CLIK):
Comments:
Goal 2:
Goal Completion Date:
Goal Attainment Scaling score (Score from -2 to +2. Refer to Goal Attainment Scaling in CLIK):
Comments:
Goal 3:
Goal Completion Date:
Goal Attainment Scaling score (Score from -2 to +2. Refer to Goal Attainment Scaling in CLIK):
Comments:
Goal 4:
Goal Completion Date:
Goal Attainment Scaling score (Score from -2 to +2. Refer to Goal Attainment Scaling in CLIK):
Comments:
Total Goal Attainment Scaling score:(Sum of all Goal Attainment Scaling scores):

Goal Scoring

Converted Goal Attainment Scaling score:(Instructions on how to convert scores are found in the attached Goal Attainment Scaling Score Conversion Table):
Rehabilitation Provider Comments
The provider’s opinion regarding the client’s vocational, psychosocial and medical management rehabilitation, and comments about the client’s attitude, strengths, possible future barriers and long-term needs.

Sign-Off and Distribution

The sign-off must include certification that the closure of the Rehabilitation Plan has been done in consultation with stake holders. Sign-off will acknowledge the key stakeholders, including:
  • Client
  • Rehabilitation service provider
  • Rehabilitation co-ordinator(delegate)
  • Others such as treating doctor(s) and an employer (if appropriate).

Closure of this Rehabilitation Plan has been done in consultation with the following stakeholders:
Client’s signature: / Date:
Rehabilitation provider’s signature: / Date:
Other signatures:(see examples above) / Date:
  1. Has the client been provided with documentation regarding their rights and obligations following the closure of their Rehabilitation Plan?
The Rehabilitation co-ordinator (delegate) is responsible for providing the client with the Rights and Obligations document at the time of closure. The Rehabilitation co-ordinator (delegate) should acknowledge the client has received the document and then sign-off the Closure Report before distributing copies to all stakeholders.
Yes No
Rehabilitation co-ordinator’s (delegate’s) first name:
Delegate’s initials and number: / Date:

Providers scan and email PDF of this form and the LSI, to assist with reporting requirements, to:

South Australia/Victoria /
Northern Territory/Tasmania/Western Australia /
Queensland (Postcode 4729 and below) and NSW (less Postcodes 2500-2599, 2600-2699 and 2900-2999) /
North Queensland (Postcode 4730 and above) and NSW/ACT (Postcodes 2500-2599, 2600-2699 and 2900-2999) /

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.

To read more visit http://www.dva.gov.au/site-information/privacy/privacy-notice-%E2%80%93-financial-and-health-information.

This page is intentionally blank

Cost Breakdown Table
Do not provide this page to client.

Breakdown rehabilitation provider costs as set out in the table. Costs are GST inclusive.

Reports ($)
Case management activities ($)
Job placement ($)
Travel ($)
Other ($)
Total ($)
Rehabilitation provider / Name:
Signature: / Date:
DVA rehabilitation
co-ordinator (delegate) / First Name:
Delegates initials and number: / Date:

For assistance phone DVA on 133 254 (metropolitan callers) or 1800 555 254 (regional callers). Last updated: 03 February 2017

Client Name: ______Defcare Case ID: ______

Rehabilitation Closure Report - D1335Page 1

Goal Attainment Scaling Scores Conversion Table

The client’s Goal Attainment Scaling scores are convertedby use of this table.The conversion combines both the number of goals with the Total Goal Attainment Scaling Score (TGASS).This table is not the LSI.

To convert the TGASS to a final score,find the number that represents the client’s combinedGoal Attainment Scaling scores in the TGASS column in the table below. Then find the intersection between the TGASS and the number of goals in the plan (from one to four). For example, TGASS of +4 where there are 4 goals gives a converted score of 65.

A converted score of 50 is where the “expected outcomes” have been achieved. Below 50 means the outcomes are “less than expected” or “most unfavourable”.

Total Goal Attainment Scaling Score (TGASS)
/ Number of Goals in Rehabilitation Plan
1 / 2 / 3 / 4
+8 / 79
+7 / 75
+6 / 77 / 72
+5 / 73 / 68
+4 / 75 / 68 / 65
+3 / 69 / 64 / 61
+2 / 70 / 62 / 59 / 57
+1 / 60 / 56 / 55 / 54
0 / 50 / 50 / 50 / 50
-1 / 40 / 44 / 45 / 46
-2 / 30 / 38 / 41 / 43
-3 / 31 / 36 / 39
-4 / 25 / 32 / 35
-5 / 27 / 32
-6 / 23 / 28
-7 / 25
-8 / 21

For assistance phone DVA on 133 254 (metropolitan callers) or 1800 555 254 (regional callers). Last updated: 03 February 2017

Client Name: ______Defcare Case ID: ______

Rehabilitation Closure Report - D1335Page 1