Claim and Service Details:

• Date(s) of Assessment: 12 August 2026 (initial), 19 August 2026 (final)
• Claim Number: WSIB Claim #6247193
• Date of Injury or Workplace Event: 3 March 2026
• Referral Source and Reason for Referral: Referred by WSIB Case Manager Mr Novo Psych to determine psychological diagnosis, functional impact, and an appropriate treatment plan following a workplace incident
• Modality: In person, approximately 90 minutes per session
• Assessing Psychologist: Dr Sarah Green, Registered Psychologist, College of Psychologists and Behaviour Analysts of Ontario

Consent and Review of Findings:

• Mr Brown provided verbal and written consent for the assessment and for release of this report to WSIB, and was advised that the report would be used to inform decisions regarding his claim and treatment funding
• Findings were reviewed with Mr Brown at the conclusion of the second appointment; he agreed with the diagnostic impressions and functional limitations outlined below and did not raise disagreement with the recommendations made

Workplace Event and Reported Onset:

• Workplace event(s): On 3 March 2026, while operating a forklift in a warehouse, a stack of pallets collapsed nearby, narrowly missing Mr Brown and injuring a co-worker; he described the event as sudden and life-threatening and returned to work the following day
• Onset and course of symptoms: Hypervigilance, intrusive memories of the incident, and sleep disturbance began within days of the event; continued working modified duties for approximately six weeks before ceasing work entirely on 20 April 2026 due to worsening anxiety and avoidance of the workplace

History and Subjective Report:

• Presenting symptoms: Recurrent intrusive memories of the pallet collapse, hypervigilance in response to machinery noise, sleep-onset difficulty, and irritability; rated day-to-day anxiety as “an eight out of ten most days”
• Impact on daily life: Waking three to four times nightly, reduced concentration affecting reading and driving, avoidance of the warehouse and similar industrial settings, and increased irritability with partner and children
• Current work status: Off work since 20 April 2026; has not attempted a return to work since ceasing duties
• Personal and social history relevant to the injury: No prior history of anxiety or trauma-related symptoms reported; twelve years’ experience as a warehouse operator without previous workplace incidents
• Substance use: Increase in evening alcohol consumption (two to three standard drinks most nights) since ceasing work, attributed to difficulty settling to sleep
• Strengths and supports: Supportive partner; engaged appropriately with the assessment process; expressed motivation to return to work once symptoms improve

Psychological Testing and Measures:

• PTSD Checklist for DSM-5 (PCL-5), administered 12 August 2026: total score 52 (clinical cut-off 33), consistent with a probable diagnosis of PTSD
• Generalised Anxiety Disorder 7-item scale (GAD-7), administered 12 August 2026: score 14, moderate range
• No clinical indication of symptom exaggeration or invalid responding noted, although no formal validity measure was administered
• Both measures will serve as baseline scores for tracking progress during treatment

Pre-existing and Co-existing Conditions:

• Pre-existing psychological conditions: None reported
• Co-existing psychological conditions: Mild low mood, judged by Dr Green to be secondary to reduced income and prolonged inactivity since ceasing work rather than an independent condition
• Physical injuries and health conditions: No physical injury sustained during the workplace event; co-worker was injured
• Relationship between conditions: In Dr Green’s opinion, the low mood is a consequence of the primary trauma-related presentation and extended work absence, rather than a pre-existing or unrelated condition

Risk Screening:

• Imminent risk: Denied current suicidal ideation, self-harm, or risk to others at both appointments; no prior history of self-harm or suicide attempts reported
• Action taken: No safety planning or escalation required

Barriers to Recovery and Return to Work:

• Avoidance of the warehouse environment and machinery noise
• Fear of re-injury
• Sleep disruption affecting daytime functioning
• Increased evening alcohol use, which may interfere with morning functioning and treatment engagement

Diagnosis:

• Posttraumatic Stress Disorder (DSM-5-TR, 309.81/F43.10), based on exposure to a life-threatening event and the presence of intrusion, avoidance, negative alterations in mood and cognition, and hyperarousal symptoms persisting beyond one month with clinically significant distress and functional impairment
• Differential and rule-outs: Adjustment Disorder with Anxiety considered but ruled out given the presence of a qualifying Criterion A trauma exposure and the full PTSD symptom cluster
• Relationship to the workplace injury: In Dr Green’s clinical opinion, the diagnosis is causally related to the workplace incident of 3 March 2026, with no alternative precipitant identified

Functional Abilities:

• Cognitive functioning: Difficulty sustaining attention for periods longer than approximately twenty minutes, affecting ability to read safety documentation and maintain the sustained vigilance required to operate machinery
• Emotional and behavioural functioning: Reduced tolerance for unexpected loud noises; increased irritability under time pressure
• Interpersonal functioning: Generally preserved within the family; withdrawal from social contact with former co-workers
• Work-relevant capacities: Currently unable to tolerate exposure to the warehouse or forklift environment; would require a graded return with modified duties; currently unable to sustain a full working day
• Daily living: Self-care intact; household tasks reduced due to fatigue associated with poor sleep
• Current limitations and restrictions: Not fit for a return to pre-injury duties at this time; capacity for a graded return to modified, non-warehouse duties to be reassessed following the initial treatment block

Treatment Plan:

• Recommended treatment: Trauma-focused cognitive behavioural therapy (TF-CBT), delivered weekly, incorporating graded exposure to machinery- and warehouse-related cues, given the identified avoidance pattern and its role in maintaining symptoms
• Treatment goals: Reducing PCL-5 score below the clinical cut-off within twelve sessions; tolerating the presence of warehouse-type machinery noise without significant distress; achieving at least six hours of consistent sleep nightly. Mr Brown described his own goal as wanting to “feel safe enough to go back to the floor”
• Number of treatment blocks requested: One block of twelve sessions, based on the severity of current PCL-5 and GAD-7 scores and the complexity of the avoidance pattern described
• Proposed measures for tracking progress: PCL-5 and GAD-7 to be repeated every four sessions, alongside clinician rating of progress against each treatment goal
• Anticipated barriers to treatment: Current evening alcohol use as a sleep aid may interfere with engagement; to be addressed early in treatment through psychoeducation, with referral to Mr Brown’s family physician if it does not resolve

Other Recommended Assessments or Treatments:

• Referral to Mr Brown’s family physician regarding sleep difficulty and evening alcohol use
• Psychiatric consultation to be considered if no meaningful improvement is observed following the initial treatment block

Communication and Next Steps:

• Contact with the case management team: Report to be forwarded to WSIB Case Manager Mr Novo Psych on completion
• Next appointment: First treatment session scheduled for 28 August 2026, in person
• Pending items: Workplace incident report requested from the employer to corroborate the reported event; currently pending

Assessment Summary:

Mr Brown was referred for assessment following a workplace incident on 3 March 2026 in which a stack of pallets collapsed nearby while he was operating a forklift. He presents with Posttraumatic Stress Disorder, supported by PCL-5 and GAD-7 scores in the probable and moderate ranges respectively, with functional limitations affecting concentration, tolerance of machinery noise, sleep, and capacity to work in a warehouse environment. No current risk to safety was identified. A block of twelve sessions of trauma-focused cognitive behavioural therapy is requested, targeting avoidance and hyperarousal symptoms, with progress tracked against baseline PCL-5 and GAD-7 scores and the treatment goals outlined above.