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CNESST 5005-R: Psychological Evaluation Report

Psychologists, psychotherapists and neuropsychologists complete this four-page CNESST report after evaluating a worker with an employment injury who was referred by prescription from their treating health professional. It records the referring diagnosis, evaluation dates, case history, factors affecting psychological and social functioning and return to work, the worker's perception, analysis and conclusions, and an individualized intervention plan if treatment follows.

Who completes it

The psychologist, psychotherapist or neuropsychologist who performed the evaluation completes and signs the whole report, attaching the Informations communes aux rapports page from the Compte de soins ou de services de psychologie ou de psychothérapie (form 5008).

Submitting and payment

How to submit it
Send it within 15 days of the last meeting it covers through CNESST's Envoi de document online service or by fax, and send a copy to the worker's treating health professional.
Who pays
CNESST pays for the evaluation at its hourly rate, with report-writing time payable up to 2 hours (8 hours for a neuropsychological evaluation) billed on form 5008, and the worker cannot be billed for covered services.

Good to know

  • The worker must have a prescription from their treating health professional; the report starts with the diagnosis or reason that led to the referral and the period of care provided.
  • The neuropsychological section covers behaviour during meetings and testing across cognitive, motor, somatosensory, affective, personality and perceptual spheres, plus validity scale results.
  • If intervention follows, the plan sets out the clinical approach, goals, therapeutic activities, expected participation, progress indicators, prognosis, start date and number and frequency of sessions.
  • Reports are required for payment, and the current version is 5005-R (2026-01), published in French.

Get the official form

Download the current version from the source each time; forms change without notice.

Rapport d'évaluation psychologique, psychothérapeutique ou neuropsychologique

Psychological, Psychotherapeutic or Neuropsychological Evaluation Report

Official pagePDF

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How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms change without notice, so download the current version from the official page before you fill it in.

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Frequently asked questions

When is the CNESST psychological evaluation report due?

Within 15 days of the last meeting the report covers. Send it to CNESST through the Envoi de document online service or by fax, and send a copy to the worker's treating health professional, as CNESST's page requires. Attach the Informations communes aux rapports page from form 5008.

Does the worker need a prescription for a CNESST psychological evaluation?

Yes. CNESST's page states that the worker must have a prescription from their treating health professional. The report's first section asks for the diagnosis given by that professional that led to the referral or, where applicable, the reason for the referral, along with the dates of care provided.

Is form 5005-R used for psychosocial rehabilitation services?

No. Form 5005-R is for evaluations following a treating professional's prescription. Psychosocial intervention services that CNESST itself requests in rehabilitation, under a professional-services contract, use the separate evaluation report 1844 and then the progress or final report 1845.