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Yukon WSCB Psychological Functional Abilities (F-0071)

Psychologists treating a Yukon worker's accepted psychological injury use this one-page form to tell the worker, employer and WSCB which accommodations would allow a return to work. It either confirms no functional limitations or ticks accommodations such as time off for counselling, reduced hours, reduced cognitive demands and gradual re-exposure to feared situations, with an estimated duration in days.

Who completes it

The treating psychologist, or a psychiatrist authorized by WSCB, completes and signs the form after reviewing it with the worker. The worker receives a copy to share with the employer within 24 hours.

Submitting and payment

How to submit it
Send it to WSCB by fax or mail with your initial assessment, and again whenever the worker's abilities change; the worker's copy goes to the employer within 24 hours.
Who pays
Fees follow the WSCB fee schedule, and by signing you certify that the fees charged are in accordance with it and that you have received no prior payment.

Good to know

  • Part B is headed 'For Patients Exposed to a Traumatic Event at Work' and lists 13 accommodations, from temporarily leaving the job site to arranging transportation to work.
  • Give further details for the starred items: reduced exposure to reminders or triggers, limitations due to medications, and reduced hours.
  • Policy 3.16 requires a written initial assessment report within two days of the assessment, with this form, and expects providers to share functional abilities information with the employer.
  • Psychological service providers need a signed agreement with WSCB, and WSCB may order an independent psychological assessment where the evidence conflicts.

Get the official form

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

Psychological functional abilities form

Official pagePDF

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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

When is the Yukon psychological functional abilities form required?

Under WSCB policy 3.16, psychological service providers submit a Functional Abilities Form for psychological injuries as part of the initial assessment, and thereafter any time the worker's abilities change. The written initial assessment report, outlining the assessment, diagnosis and treatment plan, is due within two days of the initial assessment.

Who sees the psychological functional abilities form?

The worker, the employer and WSCB. You certify that you reviewed the details with the worker and gave them a copy, and the worker's copy is to be shared with the employer within 24 hours. Policy 3.16 says the goal of sharing is to help the worker recover and return to work as soon as it is safe.

Does this form record a diagnosis?

No. It lists only functional limitations and the accommodations that would let the worker return to work, plus an estimated duration in days. Diagnosis, test results and the treatment plan go on the Psychological initial assessment report (F-0077), and later updates on the Psychological progress report (F-0075).