North West Persistent Pain Program Referral - (OPAL – NW)
The NW Persistent Pain Program- (OPAL-NW) is a free multi-disciplinary group program run by Simon West (Exercise Physiologist) & Bernadette Smith (Psychologist). Both have specialist training in chronic pain having competed their Masters of Science in Medicine (Pain Management) at the University of Sydney. The program involves an initial assessment followed by 6 half day pain education sessions and post program review. The program helps people understand their pain and the role of self-management to improve quality of life and functionality in the presence of persistent pain. 
Referrer Details (stamp allowed)
Date: <<Miscellaneous:Date>>
Referrer Name: <<Doctor:Name>>	Practice/Organisation: 
<<Practice:Name>>	Address: <<Doctor:Address>>	Phone: <<Doctor:Phone>>	Fax: <<Doctor:Fax>>			Client Details
First Name: <<Patient Demographics:First Name>>	Surname: <<Patient Demographics:Surname>>	Date of Birth: <<Patient Demographics:DOB>>	Gender: <<Patient Demographics:Gender>>
Address: <<Patient Demographics:Address>>	Phone: <<Patient Demographics:Phone (Home)>>	<<Patient Demographics:Phone (Mobile)>>	

Pain Related Information (Required) - Diagnosis (if known); relevant medical history (inc. Hx mental health, Hx drug dependence); results of investigations/findings; functional status and psychological distress; history of treatment for pain; current medication
<<Clinical Details:Medication List>>
<<Clinical Details:History List>>	
Client Eligibility
Persistent Pain >3 months (moderate-high intensity, non-cancer)  <<Persistant pain > 3months (mod-high, non cancer)>>
Pain that is distressing and continues despite reasonable medical treatment <<Pain that is distressing & continuous with med Tx>>
Not waiting for (or considering) pain related surgery or interventions <<Not waiting for pain related surgery/intervention>>
Not currently under a workers compensation or MAIB claim <<Not currently under a workers comp or MAIB claim>> 
Not suffering from untreated mental health (or drug related) condition <<No untreated mental health/drug condition>>	

Preferred Location
 <<Preferred location>>

Referral to:
OPAL Referral
Attention: Ms Gaylie Harman 
Psychology Plus (Tas) Pty Ltd 
PO Box 1337
BURNIE TAS 7320
Fax: (03) 6431 9950	Enquiries:
Gaylie/Kelly– 
Phone: 6431 9959
Email: admin@psychologyplus.org
Fax: (03) 6431 9950	

Referred patients will be initially assessed by Bernadette Smith, Registered Psychologist and/or Simon West, Exercise Physiologist prior to being accepted into the program. GPs will receive a letter upon receipt of referral, entry to the program and a report at program completion.	

Signature:   		Date: