Injury/Illness Details

Occupation/Job Title *

Date of Injury/Illness *

Injury and work related information (please provide a description of the work-related injury or illness *

Medical History

Brief medical history relevant to the injury *

Psychological History

Brief history of mental health difficulties including any previous psychological treatment or counselling *

Symptoms and Impact on Work

Describe the psychological symptoms that you are currently experiencing *

How has the injury or illness affected your ability to perform your job duties *

Collateral Information to Support

Would you like to add any documentation related to your claim (e.g., GP certificate of capacity, referral)?. Please include this when returning this form. *

YesNo

Documentation related to your claim

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Injury Claims Client Enquiry Form (Work Cover, TAC & CTP)

Case Manager Information

Injury/Illness Details

Medical History

Psychological History

Symptoms and Impact on Work

Collateral Information to Support