Report Template:
Designed for DVA clinicians using a Mentalization Based Treatment (MBT) framework, this template provides a draft End of Cycle Report. It may be useful in instances where the information contained in the template is first provided through a dictated note using NovoNote.
DVA Treatment Cycle – End of Cycle Report for Allied Health Providers
Client Details
- Name
- Date of birth
- DVA file number
- Referring clinician
- Referral date for this cycle
- Previous treatment summary
Conditions Being Managed
- List of conditions being managed for the client
Client Goals and Date Assessed
- List client’s individual goals, followed by its status (Not met/Ongoing/Achieved)
Management Summary
- Summarise the therapeutic approach and interventions provided during the cycle
- Treatment focus and therapeutic strategies, and ongoing plans
- Recommendations for further support
Outcome Measures
- Measure name
- Initial assessment score and date
- Start of cycle score and date
- End of cycle score and date
Interpretation of Outcome Measures and Additional Comments
- Provide a detailed interpretation of scores and implications
- Further management required (Y/N)
- Reasoning to support recommendation
Allied Health Provider Details
- Name, provider number, profession
- Practice name and address
- Contact details (phone, fax, email)
- Provider signature and date
DVA Treatment Cycle – End of Cycle Report for Allied Health Providers
Client Details
Name: Mary Blogs
DOB: 15/07/1985
DVA file number: NN999999
Referring clinician: Dr. John Jones, Psychiatrist
Referral date for this cycle: 12/02/2025
Previous treatment: Completed 16 sessions of trauma-focused CBT with psychologist in 2023. Previous engagement with community mental health services following discharge from inpatient psychiatric unit in 2022.
Conditions Being Managed
- Post-Traumatic Stress Disorder
- Borderline Personality Disorder features
- Complex trauma history
- Chronic depression
Client Goals and Date Assessed
- Develop capacity to recognise and regulate emotional states without self-harm behaviours. Status: Ongoing
- Improve interpersonal relationships through enhanced mentalizing capacity. Status: Ongoing
- Reduce frequency and intensity of dissociative episodes. Status: Achieved
- Establish consistent sleep patterns and daily routine. Status: Not met
- Return to part-time employment within 12 months. Status: Ongoing
Management Summary
Mary engaged in a 20-session cycle of Mentalization Based Treatment focusing on developing mentalizing capacity and emotional regulation skills. Treatment emphasised the “not-knowing” stance and curiosity about mental states, with particular attention to moments of mentalizing breakdown during sessions. Interventions included psychoeducation about attachment and mentalizing, exploration of internal working models developed through childhood trauma experiences, and real-time processing of therapeutic ruptures and repairs. Significant focus was placed on Mary’s tendency toward psychic equivalence mode when discussing military trauma, with gradual development of capacity to hold alternative perspectives about traumatic memories. Sessions incorporated mindfulness-based techniques to enhance awareness of mental states and reduce emotional reactivity. Treatment also addressed interpersonal patterns through examination of therapeutic relationship dynamics, particularly Mary’s oscillation between idealisation and devaluation of the therapist. Recommendations include continuation of MBT with focus on consolidating gains in mentalizing capacity and preparation for vocational rehabilitation program.
Outcome Measures
Measure: Depression Anxiety Stress Scales-21 (DASS-21)
- Initial assessment score: DASS-21: Depression 32, Anxiety 28, Stress 35 on 15/01/2024
- Start of this cycle score: DASS-21: Depression 28, Anxiety 24, Stress 31 on 12/02/2025
- End of this cycle score: DASS-21: Depression 18, Anxiety 16, Stress 22 on 28/05/2025
Measure: Reflective Functioning Questionnaire (RFQ-8)
- Initial assessment score: RFQ-8: Certainty 3.2, Uncertainty 2.8 on 15/01/2024
- Start of this cycle score: RFQ-8: Certainty 3.0, Uncertainty 3.1 on 12/02/2025
- End of this cycle score: RFQ-8: Certainty 2.4, Uncertainty 3.6 on 28/05/2025
Measure: PCL-5 PTSD Checklist
- Initial assessment score: PCL-5: Total score 68 on 15/01/2024
- Start of this cycle score: PCL-5: Total score 61 on 12/02/2025
- End of this cycle score: PCL-5: Total score 48 on 28/05/2025
Interpretation of Outcome Measures and Additional Comments
Mary demonstrated significant improvement across all measures during this treatment cycle. DASS-21 scores showed substantial reductions in all domains, with depression scores moving from severe to moderate range and anxiety/stress scores declining to mild-moderate levels. The RFQ-8 results indicate improved mentalizing capacity, with decreased certainty about mental states (indicating reduced hypermentalizing) and increased appropriate uncertainty, suggesting more balanced reflective functioning. PCL-5 scores showed clinically significant improvement, moving from severe to moderate PTSD symptom range. These improvements align with clinical observations of enhanced emotional regulation, reduced dissociative episodes, and improved capacity for interpersonal connection. Mary’s increased ability to maintain curiosity about mental states rather than assuming certainty represents a core therapeutic gain in mentalizing capacity.
Further management required Y/N: Y
Reasoning to support recommendation: While Mary has made substantial progress in developing mentalizing capacity and emotional regulation skills, ongoing treatment is recommended to consolidate therapeutic gains and address remaining goals. Particular focus should be placed on sleep hygiene interventions and preparation for gradual return to employment. Continued MBT will support maintenance of improved mentalizing functioning and provide ongoing therapeutic relationship stability during transition to increased independence.
Allied Health Provider Details
Name: Sarah Smith
Provider number: 1234567N
Allied health profession: Clinical Psychologist
Practice name and address: 11 NovoNote Street, NovoPsych, Australia
Phone: (03) 9666 6666
Fax: (03) 9666 6661
Email: s.smith@novopsych.com.au
Provider Signature:
Date:
- Template Type
- Report
- Letter
- Note Dictation
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