Capital Region Psychological Services
Instructions on How to Complete an OCF-18 Package
You have been referred to our clinic for a psychological assessment in order to determine your
current psychological status and need for psychological treatment.
This OCF-18 package includes:
1-A questionnaire
2-A signature page
3-Once you have completed 1 and 2 you can bring them to the office and complete two brief
questionnaires in order to complete the OCF-18 process.
Once the completed OCF-18 package is complete, we will then submit an OCF-18 to the
Insurance Company to await approval for an assessment. The Insurer has 10 business days to
respond. Once we receive the response we will then be contacting you to set up an appointment
date and time.
Please note that if you have extended health (other health benefits through your work or your
significant other) we require the name of the insurer, their date of birth, the plan number and the
certificate number.
Should you have any questions or concerns please feel free to contact us.
Sincerely,
Tamara Haim
Office Administrator
Capital Region Psychological Services
Tel: 613-521-1111
Fax: 613-521-1112
Capital Region Psychological Services
OCF 18 Preliminary Questionnaire
Client’s Name: Last:_______________________________ First:_________________________________
DOB: (yyyy/mm/dd)_________________________________________
Address: _____________________________________________________________________________
_____________________________________________________________________________________
Phone: ________________________________
Date of Loss (Date of accident): (yyyy/mm/dd)________________________
Insurance company:____________________________________________________________________
Insurance company branch/ address:
_____________________________________________________________________________________
_____________________________________________________________________________________
Claim #: _______________________________
Policy #: _______________________________
Adjuster’s Name: ______________________________________________________________________
Adjuster’s Phone: _______________________
Adjuster’s Fax: __________________________
Is the Policy Holder the same as the applicant?_____________________
Policy Holder: Last Name:__________________________ First Name:___________________________
Lawyer’s Name:________________________________________
Lawyer’s Phone #: _____________________________________
Do you (or your spouse) have any extended health insurance:
YES
NO
Name of Extended Health Insurer:________________________________________________
Extended Health Policy Holder Name and Date of Birth:_______________________________________
Extended Health Policy #: ______________________________
Extended Health Plan #:________________________________
Extended Health Certificate/ID #:___________________________
Are you being treated for injuries under a MIG (Minor Injury Guidelines)
SYMPTOM CHECKLIST
Do you have difficulties with or changes in:
___ pain
___ anxiety/worry
YES
NO
___ sleep
___ change in appetite (food intake)
___ wordfinding problems
___ panic
___ fatigue
___ fear in the car/as a pedestrian/in a bus
___ concentration/attention
___ memory
___headaches
___ depression/sadness
1) Please briefly describe the accident:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
2) Please describe the injuries you sustained during the accident:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
3) Did you hit your head at the time of the accident? If yes, did you sustain a head or brain injury?
_____________________________________________________________________________________
4) Do you know if you received a catastrophic designation?
_____________________________________________________________________________________
5) Since the accident, have you undergone any psychological assessment or treatment? If so,
When:_______________________________________________________________________________
With whom: (name of psychologist)________________________________________________________
6) What treatments are you currently involved in (please list names of therapists/treating consultant
and phone numbers)?
_____________________________________________________________________________________
_____________________________________________________________________________________
7) Have you previously been seen by Dr. Rossy/Dr. Hall? If yes, when:
_____________________________________________________________________________________
8) What symptoms have you experienced after the accident?
_____________________________________________________________________________________
_____________________________________________________________________________________
9) Since the accident have you felt more sad or depressed? If so, please describe:
_____________________________________________________________________________________
_____________________________________________________________________________________
10) Since the accident have you experienced any changes in your sleep patterns? If so, please describe:
_____________________________________________________________________________________
_____________________________________________________________________________________
11) Since the accident have you experienced any changes in appetite? If so, please describe:
_____________________________________________________________________________________
_____________________________________________________________________________________
12) Since the accident have you felt more anxious or worried? If so, please describe:
_____________________________________________________________________________________
_____________________________________________________________________________________
13) Since the accident, have you felt more fearful while driving, being a passenger, and/ or a pedestrian?
If so, please describe: ___________________________________________________________________
_____________________________________________________________________________________
14) Since the accident have you experienced flashbacks or nightmares? If so, please describe:
_____________________________________________________________________________________
_____________________________________________________________________________________
15) If you have experienced pain symptoms since the accident, what kind of things do you do to cope
with or minimize your pain? ______________________________________________________________
_____________________________________________________________________________________
16) Have you returned to your to the following activities since the accident?
Work
School
Driving
Household duties
Leisure/Recreation
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
Not applicable
Not applicable
Not applicable
Not applicable
Not applicable
If yes to any of the above, please describe:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________
17) Are you on any medications that you did not take prior to the accident? If so, please list:
_____________________________________ ____________________________________________
_____________________________________ ____________________________________________
18) Are you undergoing any kind of treatment at this time? (physiotherapy, massage therapy, etc.)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
19) Were you working at the time of your accident?
YES
NO
If so, have you been able to return to work since your accident?
_____________________________________________________________________________________
_____________________________________________________________________________________
19) Have you seen a psychologist, psychiatrist or counselor before the accident? YES NO
If so, when, for how long?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________________________________________________________
20) Have you been assessed by a psychiatrist, psychologist or a counselor after your accident? When?
Were you treated by them? How long was the
treatment?____________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
For all accidents after September 1/2010, please attach a copy of your automobile insurance policy
and statement from automobile insurer regarding med/rehab funds spent to date.
Additional Comments:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________