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VAC 1753: Follow-up Mental Health Questionnaire (VIP)

Veterans Affairs Canada uses this follow-up questionnaire to reassess whether a client's mental health condition still impairs their instrumental activities of daily living (IADLs) and self-sufficiency at home, for continued Veterans Independence Program (VIP) assistance. It repeats the initial questions on housekeeping, grounds maintenance, errands and meals, and adds a recommendation on whether benefits should be short-term or long-term.

Who completes it

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

Good to know

  • Question III asks you to choose between a short-term arrangement of 12 months and long-term benefits, because the client is unlikely to improve to the point where services are no longer needed.
  • VIP is assessed on impairment: the client must need moderate to significant assistance with IADLs to remain self-sufficient in their principal residence.
  • For any IADL where you recommend assistance, describe the specific barriers that stop the client from completing the task and staying self-sufficient at home.
  • The current edition is dated 2026-03, published in English and French, and follows the initial questionnaire, VAC 1752, first issued in October 2025.

Get the official form

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

Follow-up Mental Health Questionnaire for the Veterans Independence Program

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

Official pagePDFVersion française

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

How is VAC 1753 different from VAC 1752?

VAC 1753 is the follow-up version used to reassess a client already considered for VIP. It asks the same questions about the condition treated and the four IADLs, and adds question III, where you recommend benefits either short-term, for 12 months, or long-term if the client is unlikely to improve.

Which IADLs does the VIP follow-up questionnaire cover?

Cleaning, vacuuming or other housekeeping; grass cutting, snow removal or other grounds maintenance; leaving home to complete errands; and preparing or accessing nutritional meals. VIP contributes to the cost of these services, and VAC only provides the funding, so clients find their own service providers.