This form contains 122 fields organized into 38 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name	Type	Description
Activity or participation goal (Goal 2)
Goal 2: Activity or participation goal	Text	Enter the person’s activity or participation goal for Goal 2 — a clear, specific SMART statement of what the person will do or participate in (what), any conditions or limits (how/where), and the target timeframe or deadline (when). Fill only if 'Working at time of injury' is 'No'.
Anticipated additional sessions and discharge date
Anticipated additional sessions	Text	Enter the number of additional therapy sessions you anticipate will be required before discharge (use digits, e.g., 0, 1, 2).
Anticipated discharge date	Date	Enter the expected discharge date for the person with the injury.
Assistance options (insurer / case conference / consultant)
Direct contact from the insurer	Checkbox	Check this box if you would like the insurer to make direct contact to assist with the person’s recovery or claims management.
Case conference	Checkbox	Check this box if you would like a case conference arranged (the form may ask you to specify who should attend).
Case conference — who with	Text	Enter the name(s) or organisation(s) of the person(s) you want involved in the case conference (e.g., clinician, insurer representative, family member). Fill only if 'Case conference' is 'Yes'. Depends on: Case conference
Collaborative case review with an independent consultant	Checkbox	Check this box if you would like a collaborative case review conducted by an independent consultant to support the treatment plan.
Barriers to recovery identified through screening and assessment
Barrier to recovery (1)	Text	Enter the barrier to recovery identified through your screening and assessment — provide a brief, specific description of the issue or factor that is limiting recovery (for example: pain, mental health, social or workplace barriers).
Collaboratively developed treatment plan (Yes/No) and explanation
Collaboratively developed treatment plan - Yes	Checkbox	Check this box when the treatment plan was developed together with the person with an injury (they participated in creating the plan).
Collaboratively developed treatment plan - No	Checkbox	Check this box when the treatment plan was not developed with the person with an injury (they did not participate in creating the plan).
Reason plan was not collaboratively developed	Text	Enter a clear explanation of why the treatment plan was not developed collaboratively with the person with an injury, giving specific reasons, circumstances and any relevant details. Fill only if 'Collaboratively developed treatment plan - No' is 'Yes'. Depends on: Collaboratively developed treatment plan - No
Compensable injury/illness
Compensable injury/illness	Text	Enter the compensable injury or illness being treated for this claim as a short description (for example a diagnosis and affected body part or brief summary of the injury/illness).
Current clinical signs and symptoms
Current clinical signs and symptoms	Text	Describe the person’s current presenting signs and symptoms related to the injury or illness, including location, nature (e.g. pain, numbness, weakness), severity, onset and duration, and any factors that relieve or worsen them.
Current Usual activities (activities of daily living, driving, transport, leisure) - Current capacity
Current capacity — Usual activities	Text	Describe what the person can do now in relation to usual activities (activities of daily living, driving, transport and leisure), including any limitations compared with before the injury.
Current Work (occupation, tasks, days/hours) - Current capacity
Current capacity — Work (occupation, tasks, days/hours)	Text	Describe what the person can do now in relation to their work, including current occupation or role, typical tasks they are able to perform, and the days/hours they can work.
Details of pre-existing conditions
Pre-existing conditions (details)	Text	Enter a clear description of any pre-existing or prior medical conditions directly relevant to the compensable injury, including diagnoses, brief history, prior treatments or symptoms and any dates or other details that explain their relevance.
If discharge date changed, explain why
Explanation for change to anticipated discharge date	Text	Provide a brief clear explanation of why the anticipated discharge date in this plan is different from the date in the last plan, including relevant circumstances or events and any changed timing. Fill only if 'Anticipated discharge date' has changed since the last plan. Depends on: Anticipated discharge date
Insurer contact and signature
Insurer contact name	Text	Enter the full name of the insurer representative who can be contacted about this decision.
Insurer signature	Text	Provide the insurer representative's signature or printed name as required to confirm the decision.
Insurer phone number	Text	Enter the insurer contact's phone number for follow-up, including country and area code if applicable.
Signature date	Date	Enter the date when the insurer representative signed the form.
Insurer email address	Text	Enter the email address for the insurer contact to receive correspondence about this decision.
Insurer decision - Explanation
Insurer decision — Explanation	Text	Provide a clear, detailed explanation of the insurer's decision (for example, reasons for approval, approval of some services only, decline, or request for more information) that documents why the decision was made and any supporting points. Fill only if 'Approval of some services only', 'Declined', 'More information required' is 'Yes' (any). Depends on: Approval of some services only, Declined, More information required
Insurer decision - Options
Approved	Checkbox	Check this box when the insurer approves all of the requested services as submitted (no additional conditions or exclusions).
Approval of some services only	Checkbox	Check this box when the insurer approves only certain requested services and not others, and provide an explanation of which services are approved and which are not.
Declined	Checkbox	Check this box when the insurer declines all requested services and provide the required explanation and supporting documentation for the decision.
More information required	Checkbox	Check this box when the insurer cannot make a decision until additional information is provided and specify what information is needed.
Interpretation of score(s)
Interpretation of score(s)	Text	Enter a clear, concise interpretation of the reported outcome measure scores (summary of what the scores mean for the person’s function, progress or clinical status). Fill only if 'Row 1 Measure', 'SOM Row 2 - Measure', 'Row 3 - Measure name' are filled (any). Depends on: Row 1 Measure, SOM Row 2 - Measure, Row 3 - Measure name
Person with an injury - Section 1
Section 1 — Name of person with an injury	Text	Enter the full name of the person who sustained the injury.
Section 1 — Date of birth	Date	Enter the person's date of birth.
Section 1 — Pre-injury occupation	Text	Provide the person's usual occupation or job title before the injury occurred.
Section 1 — Pre-injury work hours per week (average)	Number	Enter the average number of hours per week the person worked before the injury.
Section 1 — Claim number	Text	Enter the insurer or compensation claim number associated with this person's case.
Section 1 — Date of injury/crash	Date	Enter the date on which the injury or crash occurred.
Position description copy (Yes/No)
Position description copy - Yes	Checkbox	Check this box if you have a copy of the position description / work duties (including workers compensation and, where relevant, CTP).
Position description copy - No	Checkbox	Check this box if you do not have a copy of the position description / work duties (insurer to provide if not available).
Practice details
Practice email	Text	Enter the email address used by the practice for correspondence about this claim.
Best time/day to contact	Text	Provide the preferred time or day to contact the practice (for example, mornings, afternoons, weekdays or specific days).
Practice name	Text	Enter the full name of the medical or treatment practice providing services.
SIRA approval number (workers compensation only)	Text	If applicable, enter the SIRA approval or registration number for workers' compensation services; leave blank if not applicable.
Suburb	Text	Enter the suburb or locality where the practice is located.
State	Text	Enter the state or territory (abbreviation or full name) where the practice is located.
Postcode	Number	Provide the postcode for the practice address.
Phone number	Number	Provide the main phone number for the practice for contact regarding the claim.
Fax	Number	Provide the practice fax number if available.
Pre-injury Usual activities (activities of daily living, driving, transport, leisure) - Pre-injury capacity
Pre-injury usual activities	Text	Describe the person’s usual activities before the injury, including daily living tasks, driving, transport use and leisure activities, and any relevant details about frequency or responsibilities.
Pre-injury Work (occupation, tasks, days/hours) - Pre-injury capacity
Pre-injury occupation, tasks and days/hours worked	Text	Enter the person’s job title and a brief description of their pre-injury work duties, typical tasks and the usual days or hours worked per week before the injury.
Previous treatment plan goals achieved (Yes / No / N/A)
Yes	Checkbox	Check this box when the person with an injury has achieved the goals from the last treatment plan in full.
No	Checkbox	Check this box when the person with an injury has not achieved the goals from the last treatment plan.
N/A	Checkbox	Check this box when the question about achievement of previous treatment plan goals is not applicable.
Rationale for the services requested
Rationale for requested services	Text	Provide a clear justification for the services being requested: describe the problem or barriers, relevant clinical or functional reasons, how the services will address the person's goals, and any expected benefits or outcomes.
Request details
Request number	Text	Enter the reference or sequential number assigned to this treatment request.
Date of request	Date	Enter the date the request is being submitted.
Date services first commenced	Date	Enter the date when allied health services first began for this injury.
Total number of consultations to date	Text	Enter the total number of consultations that have occurred to date for this injury, including the current visit.
Your allied health discipline	Combobox	Specify your allied health profession or discipline (for example, physiotherapy, occupational therapy, podiatry). Please select Physiotherapist Accredited Exercise Physiologist Other (please specify) Osteopath Psychologist Counsellor Chiropractor Example: Please select
Other discipline / details	Text	If your discipline is not listed, enter the other discipline or additional details here. Fill only if 'Your allied health discipline' Fill only if Your allied health discipline is 'Other'. Depends on: Your allied health discipline
Referred by	Text	Enter the name or source of the referrer (for example, GP, employer, insurer) who referred the person for treatment.
Phone number	Text	Provide a contact telephone number for the referrer or practitioner, including any area or country code if required.
Risk screening (tool, date, score)
Risk screening – Yes	Checkbox	Check this box when you have applied a risk screening tool during the person's assessment.
Risk screening tool name	Text	Enter the name of the risk screening instrument or questionnaire used (e.g., OMPSQ-SF, Keele STarT Back, Whip-Predict, K10). Fill only if 'Risk screening – Yes' Fill only if Have you applied a risk screening tool in your assessment? is 'Yes'. Depends on: Risk screening – Yes
Date administered	Date	Enter the date on which the risk screening tool was completed or administered to the person. Fill only if 'Risk screening – Yes' Fill only if Have you applied a risk screening tool in your assessment? is 'Yes'. Depends on: Risk screening – Yes
Risk screening score or comment	Text	Provide the numeric score from the screening tool or any brief comment/interpretation of the result. Fill only if 'Risk screening – Yes' Fill only if Have you applied a risk screening tool in your assessment? is 'Yes'. Depends on: Risk screening – Yes
Self-management strategies (between sessions)
Self-management strategies (between sessions) — Strategy 1	Text	Describe the specific self-management techniques, strategies or exercises the person is completing between sessions (e.g., home exercises, coping techniques, activity pacing), including any brief notes on frequency or duration if relevant.
Service requested - Overall total
Overall total	Number	Enter the overall total cost for all services listed in Section 5, equal to the sum of the 'Total cost' column for the service rows.
Service requested - Row 1
Row 1 — Service type	Text	Enter the service name or description requested on row 1, including consultation type and any other services (for example aids/equipment) as applicable.
Row 1 — Number of sessions/hours	Text	Enter the number of sessions or total hours requested for this service on row 1.
Row 1 — Frequency/timeframe	Text	Enter how often the service will be provided or the timeframe for row 1 (for example '1 consultation/week' or '2 hours per month').
Row 1 — Service code	Text	Enter the service or billing code that applies to this service on row 1, if applicable.
Row 1 — Cost per session/item	Number	Enter the cost per session or per item for the service listed on row 1.
Row 1 — Total cost	Number	Enter the total cost for the quantity of sessions/items requested for the service on row 1.
Service requested - Row 2
Row 2 — Service type	Text	Enter the specific service or consultation type and any other services or equipment requested for Row 2 (for example, 'speech therapy assessment' or 'mobility aid').
Row 2 — Number of sessions/hours	Number	Enter the number of sessions or total hours requested for this service in Row 2.
Row 2 — Frequency/timeframe	Text	Specify the frequency or timeframe for the Row 2 service (for example, '1 consultation/week' or 'over 6 weeks').
Row 2 — Service code	Text	Provide the applicable service code(s) for the Row 2 service, if known.
Row 2 — Cost per session/item	Number	Enter the cost per session or per item for the Row 2 service.
Row 2 — Total cost	Number	Enter the total cost for the Row 2 service (for example, cost per session/item multiplied by number of sessions).
Service requested - Row 3
Row 3 - Service type	Text	Provide a brief description of the service requested in this row, including consultation type or other services (for example, specific therapy, assessment, or aids/equipment).
Row 3 - Number of sessions/hours	Text	Enter the number of sessions or total hours required for this service (for example, 8 sessions or 4 hours).
Row 3 - Frequency/timeframe	Text	Specify how often and over what timeframe the service will be provided (for example, '1 consultation/week' or 'fortnightly for 3 months').
Row 3 - Service code	Text	Enter any applicable service or billing code used to identify this service, if available.
Row 3 - Cost per session/item	Number	Enter the cost charged for a single session or item for this service.
Row 3 - Total cost	Number	Enter the total cost for the quantity of this service being requested.
Service requested - Row 4
Row 4 — Service type	Text	Enter the service or consultation type requested for row 4, including other services or aids/equipment if applicable.
Row 4 — Number of sessions/hours	Number	Enter the total number of sessions or hours required for this service on row 4.
Row 4 — Frequency/timeframe	Text	Enter the frequency or timeframe for the service on row 4 (for example, '1 consultation/week' or '2 hours/month').
Row 4 — Service code	Text	Enter the applicable service code for this service on row 4, if one applies.
Row 4 — Cost per session/item	Number	Enter the cost charged per session or per item for this service on row 4.
Row 4 — Total cost	Number	Enter the total cost for this service line on row 4 (for example, cost per session/item multiplied by number of sessions).
Service requested - Row 5
Row 5: Service type	Text	Enter the name and short details of the service requested for row 5 (for example consultation type or aids/equipment).
Row 5: Number of sessions or hours	Text	Enter the number of sessions or total hours to be provided for this service on row 5.
Row 5: Frequency/timeframe	Text	Specify how often and over what timeframe the service will be delivered for row 5 (for example '1 consultation/week').
Row 5: Service code	Text	Enter the applicable service or billing code for this service on row 5, if available.
Row 5: Cost per session/item	Number	Enter the cost charged for a single session or item for the service on row 5.
Row 5: Total cost	Number	Enter the total cost for the quantity of sessions/items listed for this service on row 5.
SOM Row 1 (Standardised Outcome Measures - row 1)
Row 1 Measure	Text	Enter the name of the standardised outcome measure used in row 1 (for example, DASS or Neck Disability Index).
Row 1 Initial date	Date	Enter the date the first (initial) SOM was completed for this measure. Fill only if 'Row 1 Measure' is filled. Depends on: Row 1 Measure
Row 1 Initial score	Text	Enter the initial score(s) recorded when the SOM was first completed (include multi-part values if applicable, e.g. 'Depression=24 Anxiety=19' or '21/50'). Fill only if 'Row 1 Measure' is filled. Depends on: Row 1 Measure
Row 1 Previous date	Date	Enter the date of the SOM completed for submission of the previous AHTR (the prior/previous measurement date, if available). Fill only if 'Row 1 Measure' is filled. Depends on: Row 1 Measure
Row 1 Previous score	Text	Enter the score(s) recorded on the previous SOM used for the earlier submission (include component scores where applicable). Fill only if 'Row 1 Measure' is filled. Depends on: Row 1 Measure
Row 1 Current date	Date	Enter the date the latest (current) SOM was completed for this measure. Fill only if 'Row 1 Measure' is filled. Depends on: Row 1 Measure
Row 1 Current score	Text	Enter the most recent score(s) from the SOM (include component scores if the measure reports multiple sub-scores). Fill only if 'Row 1 Measure' is filled. Depends on: Row 1 Measure
SOM Row 2 (Standardised Outcome Measures - row 2)
SOM Row 2 - Measure	Text	Enter the name of the Standardised Outcome Measure for row 2 (for example, DASS, Neck Disability Index).
SOM Row 2 - Initial score date	Date	Enter the date the first/initial SOM was completed for this measure. Fill only if 'SOM Row 2 - Measure' is filled. Depends on: SOM Row 2 - Measure
SOM Row 2 - Initial score	Text	Enter the initial score recorded on the first SOM completion for this measure (e.g., 21/50 or subscale values). Fill only if 'SOM Row 2 - Measure' is filled. Depends on: SOM Row 2 - Measure
SOM Row 2 - Previous score date	Date	Enter the date the SOM was completed for the previous assessment of this measure. Fill only if 'SOM Row 2 - Measure' is filled. Depends on: SOM Row 2 - Measure
SOM Row 2 - Previous score	Text	Enter the score recorded on the SOM at the previous assessment for this measure (include subscale breakdowns if applicable). Fill only if 'SOM Row 2 - Measure' is filled. Depends on: SOM Row 2 - Measure
SOM Row 2 - Current score date	Date	Enter the date the latest/current SOM was completed for this measure. Fill only if 'SOM Row 2 - Measure' is filled. Depends on: SOM Row 2 - Measure
SOM Row 2 - Current score	Text	Enter the most recent score from the latest SOM for this measure (include subscale scores where applicable). Fill only if 'SOM Row 2 - Measure' is filled. Depends on: SOM Row 2 - Measure
SOM Row 3 (Standardised Outcome Measures - row 3)
Row 3 - Measure name	Text	Enter the name of the standardized outcome measure for row 3 (for example, DASS or Neck Disability Index).
Row 3 - Initial score date	Date	Enter the date when the initial/first completion of this SOM was carried out for row 3. Fill only if 'Row 3 - Measure name' is filled. Depends on: Row 3 - Measure name
Row 3 - Initial score	Text	Enter the score or result recorded at the initial completion of this SOM for row 3, including any subscale values if applicable. Fill only if 'Row 3 - Measure name' is filled. Depends on: Row 3 - Measure name
Row 3 - Previous score date	Date	Enter the date when the previous SOM (the one submitted for the prior period) was completed for row 3. Fill only if 'Row 3 - Measure name' is filled. Depends on: Row 3 - Measure name
Row 3 - Previous score	Text	Enter the score or result recorded on the previous SOM for this measure in row 3, including subscale values if applicable. Fill only if 'Row 3 - Measure name' is filled. Depends on: Row 3 - Measure name
Row 3 - Current score date	Date	Enter the date when the most recent/current completion of this SOM was carried out for row 3. Fill only if 'Row 3 - Measure name' is filled. Depends on: Row 3 - Measure name
Row 3 - Current score	Text	Enter the score or result recorded at the most recent completion of this SOM for row 3, including any subscale values if applicable. Fill only if 'Row 3 - Measure name' is filled. Depends on: Row 3 - Measure name
Strategies to address barriers to recovery
Strategy to address barriers to recovery	Text	Enter the planned strategies, actions or referrals to address barriers to recovery (including actions by the person, agreed team strategies, and any referrals to other services).
Treating practitioner details
Treating practitioner name	Text	Enter the full name of the treating practitioner who is completing or submitting this form.
AHPRA registration or membership number	Text	Enter the treating practitioner’s AHPRA registration or professional membership number exactly as issued (include any letters or punctuation).
Treating practitioner email	Text	Enter a valid email address for the treating practitioner where they can be contacted about this submission.
Work goal (Goal 1)
Work goal (Goal 1)	Text	Enter the person’s primary work or activity goal for Goal 1 as a concise SMART statement (what they will do or achieve, e.g., return to usual job, resume specific duties), including any target or context.
Your intervention
Your intervention	Text	Describe the intervention you will provide, including techniques, strategies or exercises the person with an injury should complete between sessions.

SIRA Allied health treatment request (Catalogue no. SIRA09191) Instructions