Referral form - Occ Psych

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Book
Organisations
PEP
Health Professionals
- Refer a client
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About
Book
Organisations
PEP
Health Professionals
- Refer a client
Fees
Employment
Contact

Application for Pain Empowerment Program (PEP)

NOTE: Each patient will be assessed on the information provided below and by our team as to the suitability for the program. Submission of this referral does not constitute automatic acceptance of the patient into the PEP program.

Referrer's name *

First

Last

Referring Practise or Organisation name *

Address of Practise or Organisation

Email address of referrer or practise *

Phone number of practise *

Fax number of practise

Patient's name *

First

Last

Patient's address *

Email address of patient *

Contact number(s) of patient *

Medicare number, IRN and expiry date *

Reason for referral (tick all that apply) *

All reasonable investigations have been completed
Reasonable and accessible management in the primary care sector has been tried with insufficient success
Pain has significant impact on life such as sleep, self-care or necessitates assistance of others
Pain is significantly impacting mobility, work or school attendance, recreation, relatiohships and/or emotions
Apparent Complex psychosocial influences relating to pain behaviour requiring specialised assessment and care
Current or past history of additction or prescribed medication use appears to be complicating current management eg; escalating opioid requirement
Difficult to control neuropathic pain is suspected
Persistent pain following trauma or surgery where there is concern regarding transition to chronic pain

Patient - History of assessment by other pain service/clinic in the past 2-5 years? If yes please provide details

Patient - Current treatment from other specialist services for the same pain problem? If yes please provide details

Psychological stressors (tick all that apply) *

A negative attitude that pain is harmful or potentially severely disabling
Fear avoidance behaviour and reduced activity levels
An expectation that passive rather than active treatment will be beneficial
A tendency to depression, low morale, low mood and social withdrawal
Financial and social pressures

Psychiatric history

Cognitive functioning

Will the patient require prior approval from an insurer to attend PEP? *

Yes
No
Unsure

Insurer and Claim Number (if applicable)

This patient's pain has been appropriately assessed and is medically fit to undertake a pain management program *

Yes

This patient consents to this referral *

Yes

Please type your name and press submit which confirms you accept the conditions of the referral and your wish to procced. *

Phone

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