Mental Health Treatment
Recovery & RTW Standard Tx
Intake Report
Intake Report must be submitted within five (5) business days of initial
session. Intake Report is not payable until the Initial Assessment Report
is received.
Date of service
(date of report yyyy-mm-dd)
Worker’s information
Worker’s last name
Date of birth
First name
Middle initial
Date of injury
(yyyy-mm-dd)
WorkSafeBC claim number
(yyyy-mm-dd)
Provider’s information
Provider’s name
Payee number
GST registration number
Mailing address
City
Phone number
Fax number
(include area code)
(if applicable)
Province
Postal code
(include area code)
Sessions
Date of initial session
(yyyy-mm-dd)
Mental health disorder(s) authorized for treatment as per referral form
DSM-5 diagnosis(es)
Return-to-work issues
Anticipated return-to-work (RTW) date
(yyyy-mm-dd)
Must be filled out as per MH Recovery and RTW Claim Summary. Contact claim owner if no date provided.
Have you received and reviewed the Mental Health Recovery and RTW Claim Summary (form 10B39)?
Yes
No
If no, please contact the claim owner.
Supporting stay at work (SAW) or RTW is a primary goal of mental health treatment. Please identify the RTW factors from form 10B39
that you will address in your treatment with this worker (e.g., mental disorder, perceived injustice, etc.).
RTW factor
Proposed intervention
RTW factor
Proposed intervention
10D108
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Mental Health Treatment
Recovery & RTW Standard Tx
Intake Report
Worker’s last name
First name
Middle initial
RTW factor
Proposed intervention
RTW factor
Proposed intervention
WorkSafeBC claim number
Additional factors
Restrictions — list any activities that the worker must not engage in for risk of immediate harm to self or others as a result of their
mental health symptoms
Describe the worker’s perception of how mental health difficulties interfere with their job performance
Describe additional supports or strategies that may promote return to work
Have you received and reviewed the worker’s job description?
Yes
No
Worker’s self-reported function (WHODAS 2.0 — 36-item version)
Provide the Average Domain Score for each WHODAS 2.0 domain (0 = None, 1 = Mild, 2 = Moderate, 3 = Severe,
4 = Extreme/Cannot do). Include comments for each item including specific examples of worker’s function, and
comment on any objective evidence of over- or under-estimation of functioning.
Understanding and communicating — cognition
Comments
/4
Getting around — mobility
Comments
/4
Self-care — hygiene, dressing, eating, and staying alone
Comments
/4
Getting along — interacting with other people
Comments
/4
Life activities — domestic responsibilities, leisure, work, and school
Comments
/4
Participation — joining in community activities
Comments
/4
Worker presentation and function (clinician report)
Please respond to the questions below. Include comments and examples where appropriate.
Did they arrive alone?
Yes
10D108
No
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Mental Health Treatment
Recovery & RTW Standard Tx
Intake Report
Worker’s last name
Comments
First name
Middle initial
WorkSafeBC claim number
(e.g., if no, was the companion required for support?)
Describe their method of transportation
Foot
Comments
Bus
Taxi
No
Comments
No
Any evidence of unusual emotional
expression?
Yes
Comments
No
Any evidence of speech difficulties?
Yes
Comments
No
Able to understand and respond
appropriately to questions?
Yes
Comments
No
Indications of loss of train of
thought or lapses of attention?
Yes
Comments
No
Behaviour socially appropriate?
Yes
Bicycle
Comments
Appropriately groomed?
Yes
Passenger
(e.g., if other mode than “Drove,” was it due to inability to drive?)
Appropriately dressed?
Yes
Drove
Comments
No
Please provide any other comments regarding the worker’s presentation or function that you believe may interfere with return to work
or social functioning
Return-to-work readiness
For workers who are not back at work in some capacity: Using the scale below, please provide an overall
estimate of the worker’s readiness to return to work from a mental health perspective.
In general, how ready is this worker to be back at work?
1
2
3
4
5
6
Not ready
Comments
7
Very ready
(identify the most responsible factors interfering with return to work)
For workers who are working in some capacity: Using the scale below, please provide an overall estimate of
the likelihood the worker will be able to stay at work, from a mental health perspective.
In general, how likely is the worker able to stay at work?
1
Not likely
10D108
2
3
4
5
6
7
Very likely
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Mental Health Treatment
Recovery & RTW Standard Tx
Intake Report
Worker’s last name
First name
Middle initial
WorkSafeBC claim number
Comments
Outline any other issues of clinical relevance not covered above
Treatment plan
Describe how the proposed treatment is related to RTW/SAW goals. Provide a description of the target symptoms,
function and/or behaviour (treatment target), and include work-specific treatment targets when appropriate.
Specify therapeutic interventions that will be employed. Define the expected functional outcome in terms of an
observable measure within a specified timeframe. This measure (e.g., behavioural target, work-specific goal)
should be used and reflected when describing progress in subsequent reports.
Treatment target 1 — symptom/function/behaviour to be addressed
Therapeutic intervention — Detailed step-by-step description of
treatment modality, strategies to be implemented, and of
rationale for intervention; worker participation activities (i.e.,
homework, exposures, readings)
Expected functional outcome and timeline — Measurable
improvement/change expected in functional or behavioural
outcome; target dates for achievement
Treatment target 2 — symptom/function/behaviour to be addressed
Therapeutic intervention
Expected functional outcome and timeline
Treatment target 3 — symptom/function/behaviour to be addressed
Therapeutic intervention
Additional treatment issues
Expected functional outcome and timeline
(specify any additional relevant treatment issues/targets to be considered)
Planning meeting
Is a meeting with the claim owner and other claim participants requested and necessary?
Yes
No
If yes, please document your discussion with the claim owner
Would communication with, or a referral to, the attending physician be beneficial?
Yes
No
If yes, has a consultation been arranged?
Yes
10D108
No
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Mental Health Treatment
Recovery & RTW Standard Tx
Intake Report
Worker’s last name
First name
Middle initial
WorkSafeBC claim number
Suicide risk assessment
* Please refer to the Mental Health Treatment Standards and Reference Manual for rating rule sets
Low*
Medium*
High*
If there are significant concerns regarding suicidality, clearly outline your care plan below
Claims Call Centre
Phone 604.231.8888
Toll-free 1.888.967.5377
M–F, 8 a.m. to 6 p.m.
Fax
604.233.9777
Toll-free 1.888.922.8807
Mail
WorkSafeBC
PO Box 4700 Stn Terminal
Vancouver BC V6B 1J1
WorkSafeBC collects information on this form for the purposes of administering and enforcing the Workers Compensation Act. That Act, along with the
Freedom of Information and Protection of Privacy Act, constitutes the authority to collect such information. To learn more about the collection of personal
information, contact WorkSafeBC’s freedom of information coordinator at PO Box 2310 Stn Terminal, Vancouver BC, V6B 3W5, or call 604.279.8171.
10D108
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