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Colorado WCM3 Mental Impairment Rating Worksheet

The AMA Guides, Third Edition (Revised) give no quantified method for rating mental and behavioral disorders, so Colorado Rule 12 requires this worksheet. The rating physician scores subcategories in four areas of function (activities of daily living, social functioning, thinking, concentration and judgment, and adaptation to stress) from 0 to 6, averages them and converts the result to a percentage.

Who completes it

A Level II accredited physician performing the mental impairment rating completes and signs it after a full psychiatric assessment. The patient's self-report informs the scores, but the patient completes nothing.

Submitting and payment

How to submit it
Include it with the written summary of the mental evaluation in the permanent impairment report sent to the insurer.
Who pays
The worksheet carries no separate fee or billing code.

Good to know

  • Average the two highest subcategory scores in each area, then the two highest area scores; clinical judgment can move the result by up to 0.5 point if justified in writing.
  • Use it only after the case meets all criteria for a DSM diagnosis, which goes at the top; chronic pain is rated within physical impairment, not here.
  • If the score is zero but the patient needs continuing medication for the DSM diagnosis, 1 to 3 percent may be assigned.
  • If apportionment applies, complete a separate worksheet for the pre-injury rating. The Division also posts guidelines for rating the areas of function.

Get the official form

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

Permanent Work-Related Mental Impairment Rating Report Worksheet

Official pagePDF

Fill it with Vero

If your copy of the form is a fillable PDF, upload it 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 and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

How is the final score calculated on the Colorado WCM3?

Each subcategory is rated 0 to 6. Average the two highest subcategories within each area of function, then average the two highest area ratings. Adjust by up to 0.5 point if clinical judgment supports it, with written justification, and convert the result with the Category Conversion Table.

Can chronic pain be rated on the mental impairment worksheet?

No. The worksheet says impairment ratings based on chronic pain do not apply within the mental and behavioral domain. They belong in a physical impairment rating, supported by physical examination with anatomic or physiologic correlation.

How is the mental rating combined with physical impairment?

Section VI of the worksheet combines the total whole person physical impairment with the psychiatric permanent impairment to give a total whole person impairment that includes the psychiatric rating. Rule 12 lets the primary care ATP determine the combined rating if Level II accredited.