L & I-Mental Health
Screening Questionnaire
Name
*
First Name
Last Name
Birthdate:
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Do you have an active and open L & I claim within Washington state?
*
Yes
No
Is your claim through a self-insured employer or third-party representative?
*
Yes
No
L & I Claim Number:
*
Name and Phone Number of Case Manager:
*
Briefly describe the work-related incident:
*
Briefly describe the mental health issues you are experiencing as a result of the work-related incident:
*
Date of the work-related incident:
*
-
Month
-
Day
Year
Date
Are you currently receiving mental health services through your L & I claim?
*
Yes
No
I am receiving mental health services NOT related to L & I claim
Submit
Should be Empty: