Psychologists in the WSIB's Community Mental Health Program report their initial assessment of a referred worker on this five-page form. It records the referral, symptom onset, behavioural observations, the worker's account of the injury, testing, pre-existing conditions, an initial work-related DSM diagnosis and functional impairments. It then sets the treatment plan in blocks and gives an opinion on safe return to occupational function.
The program psychologist completes every section, including the worker and employer details in section A, and signs the final page. The worker and employer do not complete any part of the assessment.
Download the current version from the source each time; forms change without notice.
Community Mental Health Program assessment form
Formulaire d'évaluation dans le cadre du Programme de santé mentale communautaire
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.
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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The WSIB says its mental health program of care replaces the former Community Mental Health Program, with assessments and treatment deliverable through the new program as of April 27, 2026. The CMHP forms are still listed on the WSIB's health care provider forms page, so check with the WSIB which form applies before reporting on a new referral.
Section E covers occupational function: whether the worker is at imminent risk of harm to self or others, with a plan if so; barriers to return such as harassment or lack of accommodation; whether the worker can remain at or return to safe and sustainable work; functional abilities or restrictions with expected duration; and whether a Specialty Program assessment would help.
Yes. The WSIB publishes a French version, Formulaire d'évaluation dans le cadre du Programme de santé mentale communautaire (0201B), alongside the English 0201A. Both are fillable PDFs, and dates on the form are written day, three-letter month and four-digit year.