2026-02-13 Mental Health Claims Unit Critical Incident Response Referral

WoRK BC Mental Health Claims Unit
Critical Incident Response Referral

Any urgent referrals requiring immediate contact should be made to the toll free answering service at 1.888.922.3700

Kind of referral (check one only)

Critical Incident Response: &] Supportive:
trauma counselling related to emotional response to single, emotional support for bullying and harassment and/or
sudden, unexpected incident cumulative workplace issues while claim is being adjudicated.

Worker's information

Worker's last name First name Middle initial WorkSafeBC claim number
HOLAND MARK 42647461
Address
UNIT 311 318 AGNES ST NEW WESTMINSTER BC V3L 033
Home phone &] (preferred) Cell phone (] (preferred) Other phone [] (preferred) Gender
236.994.3376 Man
Does worker require interpreter? If yes please specify language | Birth date (yyyy-mm-dd) Location (home, hospital)
Yes [No English 1978-09-04
Is someone acting on worker’s If yes, please specify name Relation to the worker Phone number
behalf?
Yes INo
Employer’s name Employer's location

BRITISH COLUMBIA RAPID TRANSIT COMPANY LTD. | attn: WorkSafeBC Contact ATTN: OCCUPATIONAL
HEALTH 6800 14TH AVE BURNABY BC V3N 4S7

Referral details
Description of the incident Incident date (yyyy-mm-dd)

W is claiming for MH concerns prompted by a loud 2026-01-30
noise in his workplace

Reason for referral Has or is the worker seeing another mental health provider or
EFAP provider in relation to this incident?

W is in distress and having difficulty managing his No

stress response

Mental health action plan details Threat codes

E T Vv P iS D MR

Are there any related issue that would make it difficult for the worker to get to the appointment

No
Is the worker currently working? Is the worker expecting a call?
Yes No & Yes No

Referral source

Submitter’s name Phone number Job title

Ms Jaylin Cassady 604.244.6306 Sr Adjudicator
Claim owner Phone number

Ms Jaylin Cassady 604.244.6306

WorkSafeBC collects information on this form for the purposes of administering and enforcing the Workers Compensation Act. That Act, along with the
Freedom of Information and Protection of Privacy Act, constitutes the authority to collect such information. To learn more about the collection of personal
information, contact WorkSafeBC’s freedom of information coordinator at PO Box 2310 Stn Terminal, Vancouver BC, V6B 3W5, or call 604.279.8171.

67B70 (18/01) Page 1 of 1