Referral Form
Pain Management
Patient Details
Name:
*
First Name
Last Name
Date of birth:
*
-
Day
-
Month
Year
Date
Pronouns:
Address:
Phone:
*
-
Area Code
Phone Number
Email:
*
example@example.com
Preferred method of contact:
*
Phone
SMS
Email
Clinical Context
Current diagnosis:
*
Pain type / classification:
*
Neuropathic - peripheral
Nociceptive
Widespread
Neuropathic - central
Nociplastic/nocipathic
Unknown / unclassified
Other
Current pain: /10
Typical pain: /10
Worst pain: /10
Frequency:
Intermittent
Daily
Continuous
Episodic
Sensory characteristics:
burning
electric/shooting
aching
pressure
stabbing
Other
Presentation and additional notes:
*
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Relevant Health Information
Current mental health diagnoses or concerns:
Current relevant medications:
Is the client currently receiving psychological or psychiatric treatment?:
*
No
Yes
Other details:
Treatment Objectives
Treatment Objectives
*
Pain intensity
Relaxation/autonomic regulation
General anxiety/stress
Pain-related distress
Fear/catastrophising
Sleep
Other
Other:
Referrer Details
Name:
*
Organisation/Practice:
*
Profession/Position:
*
Phone:
-
Area Code
Phone Number
Email:
*
example@example.com
I consent to All About You contacting me about this referral:
*
Yes
No
Signature:
Date:
-
Day
-
Month
Year
Date
Client Consent
I consent to this referral being made to All About You and understand that hypnotherapy is a complementary therapeutic intervention and does not replace medical, psychological, or psychiatric assessment or treatment where required.
I consent to All About You contacting me about this referral:
*
Yes
No
Client/Guardian Name:
*
Signature:
Date:
-
Day
-
Month
Year
Date
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ALL ABOUT YOU USE ONLY
Referral received:
Reviewed by:
Suitable for initial consultation
Further information required
Referred to alternative service / practitioner:
Initial appointment:
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