After a road-accident victim's first psychological assessment, the psychologist or psychotherapist sends this summary to the SAAQ. It gets the assessment reimbursed and authorizes balise 1, up to 15 treatment hours for psychological disorders accepted as linked to the accident. The six-page form covers the assessment, its conclusion and an intervention plan, and the 13-page package adds an invoice, a guide and writing prompts.
The psychologist or psychotherapist who did the assessment completes Sections 1 to 4, notes whether the summary was discussed with the accident victim, and signs it. Psychologists give diagnoses and personality findings, while psychotherapists summarize their clinical observations.
Download the current version from the source each time; forms change without notice.
Résumé d'évaluation initiale – Traitement de psychologie
Initial Assessment Summary – Psychological Treatment
Upload the fillable PDF once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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Balise 1 covers up to 15 treatment hours for any psychological disorder accepted as linked to the accident. Balise 2 can add up to 15 more hours, from 16 to 30, depending on severity and progress, and balise 3, an exceptional measure, covers more than 30 hours for severe and complex disorders. Each step past balise 1 needs the progress summary (4053).
The SAAQ's maximum is three hours for doing the assessment and two hours for completing this summary. Bill through the receipt or invoice page (4059 30): Section 4 if the SAAQ pays you directly, or Section 3 as a receipt if the accident victim paid. Treatment hours are claimed separately on the monthly reimbursement request (5696 30).
A psychologist or a psychotherapist in private practice, who ticks their professional title and gives their permit number from the Ordre des psychologues du Québec. Parts of Section 3 differ by title: psychologists describe mental state and symptoms and give diagnoses, while psychotherapists describe symptoms and significant psychological difficulties and summarize clinical observations.