47. A health assessment in connection with an application for financial assistance to compensate for certain disabilities must be made using the form prescribed by the Minister. It must, in particular, indicate(1) the name and contact information of the person who is a victim;
(2) the file number assigned by the Minister, if any;
(3) the date or the period in which the criminal offence was committed;
(4) the contact information of the health professional who carries out the assessment;
(5) the supplier number assigned to the health professional by the Minister, if any;
(6) the date of the meeting with the health professional;
(7) an observation of the incapacity of the person who is a victim to carry on most of the person’s usual activities;
(8) the interference that justifies the disability;
(9) the symptoms that justify the disability;
(10) the foreseeable duration of the disability;
(11) any treatment prescribed.