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WSCC Psychiatric/Psychological Initial Report (CS103)

This two-page report opens psychological care on a WSCC claim in the Northwest Territories or Nunavut. The clinician describes the presenting problem and relevant history, gives a clinical formulation or diagnosis, lists up to five primary treatment goals with the anticipated number and frequency of sessions, reports test results, and states whether there are psychological barriers to return to work and whether the worker is fit for work without restrictions.

Who completes it

The psychiatrist or psychologist completes and signs the whole report; the provider block asks for the name, registration and licence number. The worker and employer do not complete any section.

Submitting and payment

How to submit it
Email or fax it to WSCC's NWT or Nunavut claims department using the contacts on the form; WSCC's invoicing FAQ asks for medical reports within three business days of attending the worker.
Who pays
Bill the assessment separately on the WSCC Medical Invoice form, sent to Financial Services within one year of the service, since WSCC returns invoices in other boards' formats.

Good to know

  • If the worker meets only partial diagnostic criteria, the form asks you to mark the diagnosis as sub-clinical in the clinical formulation section.
  • Test results need the name of each test, evidence that the results are valid, and a summary interpretation.
  • Relevant history should note prior or current problems not related to the incident that may affect recovery.
  • Later reports go on the Psychologist Progress Report (CS102), and behavioural, cognitive and emotional restrictions go on Functional Abilities form CS104. The printed revision is CS103 0924.

Get the official form

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

Psychiatric/Psychological Initial Report

Rapport psychiatrique/psychologique initial

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

Who can complete the WSCC Psychiatric/Psychological Initial Report?

A psychiatrist or psychologist treating the worker. The form's provider block asks for the clinician's name, registration and licence number, telephone, address and date of service, and the clinician signs to certify the report is a correct statement of services they personally rendered.

What happens if the worker is not fit to return to work without restrictions?

Answer No to the fitness question on page 2 and explain any psychological barriers to return to work. The WSCC's Functional Abilities, Behavioural, Cognitive and Emotional form (CS104) is where a psychologist sets out specific restrictions, schedule limits and a graduated return-to-work plan for the employer.

Is the WSCC initial psychological report available in French?

Yes. WSCC publishes CS103 as a fillable PDF in English and in French, as Rapport psychiatrique/psychologique initial, and the English form notes that a French version is available. The same form serves workers in both the Northwest Territories and Nunavut.