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VAC 1752: Initial Mental Health Questionnaire (VIP)

Veterans Affairs Canada uses this questionnaire, introduced in October 2025, to learn whether and how a client's mental health condition impairs their instrumental activities of daily living (IADLs) and their ability to stay self-sufficient at home. The treating provider recommends assistance, or not, for housekeeping, grounds maintenance, errands and meals. If VIP is required, benefits are approved for 12 months and then reassessed.

Who completes it

The client's treating psychologist, psychiatrist or social worker completes the questionnaire, and the provider section also allows another qualified health professional, with their provincial registration number and signature. The client is identified at the top by file number and name.

Good to know

  • To qualify for VIP, the condition must impair the client's self-sufficiency, which the form defines as needing moderate to significant assistance with IADLs in their principal residence.
  • VIP contributes to routine housekeeping, such as meal preparation, laundry, cleaning and errands, and grounds maintenance, such as snow removal and lawn mowing; clients find their own service providers.
  • Where you recommend assistance, describe the specific barriers the condition creates for each task; an incomplete form may delay or affect decisions on the client's behalf.
  • You certify that the recommendations reflect your independent clinical judgement and the patient's current condition; a follow-up version, VAC 1753, is used for reassessment.

Get the official form

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

Initial Mental Health Questionnaire for the Veterans Independence Program

Questionnaire initial sur la santé mentale pour le Programme pour l'autonomie des anciens combattants

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Fill it with Vero

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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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

Who can complete VAC 1752?

The instructions say the client's treating psychologist, psychiatrist or social worker completes it. The provider section also offers Other Qualified Health Professional as a provider type, and asks for the provider's name, provincial registration number, mailing address, telephone number, signature and the date.

Which activities does VAC 1752 ask about?

Four IADLs: cleaning, vacuuming or other housekeeping; grass cutting, snow removal or other grounds maintenance; leaving home to complete errands; and preparing or accessing nutritional meals. For each, you indicate whether some level of assistance is required and then describe the specific barriers the condition creates.

How long are VIP benefits approved after VAC 1752?

The form states that if VIP is required, benefits are approved for a period of 12 months, after which a reassessment takes place. The follow-up questionnaire, VAC 1753, then asks the treating provider whether benefits should continue short-term or be put in place long-term.