NSW HEALTH 

	Facility: <<Facility patient is currently residing in>>
	Complete patient details or Affix patient label here: 

                                                           REFERRAL GUIDE TO ADULT AND PAEDIATRIC CHRONIC PAIN SERVICES	
There are a number of publicly funded multi-disciplinary chronic pain services in NSW hospitals providing expert assessment, treatment and access to a range of interventions and self management based ‘Pain Programmes’ from a biopsychosocial perspective. 

The services are time-limited and require a referral from a medical practitioner with a provider number.  This is a guide to assist practitioners to navigate the referral system and establish suitability of the client. Once received, referrals will be assessed and prioritized by the Pain Service within your Local health District, according to statewide criteria.

Indications for referral to a Pain Service 
Consider referral when the patient has chronic pain* and;•	 
•	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 some aspects of life – sleep, self care, mobility, work or school 	 attendance, recreation, relationships and/or emotions,         
    
Referrals are particularly encouraged when the patient has: 
•	  exacerbations of chronic pain that resulted in an Emergency Department presentation or hospital
admission 
•	 complex psychosocial influences on pain behavior requiring specialised assessment and care
•	 current or past history of addiction or prescribed medication use that seem to be complicating current
management (eg. an escalating opioid requirement) 
•	 difficult to control neuropathic pain
•	 difficult to control cancer pain
* Pain that is constant, and daily for a period of 3 months or more over the previous 6 months, or where 
	 the natural history of the painful condition predicts that this is likely to be the case. Also when episodic
severe pain occurs; eg. headache which interferes with daily life.

The Pain Services will require
•	 Completion of the attached referral form in full where possible

The preference of the Chronic Pain Services is 
•	 To work actively in partnership with the General Practitioner in ongoing management
•	 To work in close communication with other specialist services who are providing treatment for the same
or related problem

Statewide Priority Categories

Priority 1 – Wait time < 4 weeks 
Pain interfering with sleep or self-care, or requiring the assistance of another for activities of daily living; Children whose pain 
interferes with school attendance; Refractory cancer pain; Early neuropathic pain or complex regional pain syndrome (CRPS) 
< 3 months since onset
Priority 2 – Wait time 4-8 weeks 
Pain < 1 year not responding to GP management; frequent pain exacerbations occasioning Emergency Dept. presentations 
or hospital admissions, neuropathic pain, persistent pain following trauma or surgery, pain associated with marked physical
interference or emotional distress, children and elderly
Priority 3 – Wait time 2-3 months 
Pain > 1 year not responding to GP management, diagnostic advice, medication optimization, psychological distress, physical 
interference	

PATIENT DETAILS	
First name:: <<Patient Demographics:First Name>>	Last name::<<Patient Demographics:Surname>>	
Phone (H):<<Patient Demographics:Phone (Home)>>	Phone (W):<<Patient Demographics:Phone (Work)>>	
Phone (M):<<Patient Demographics:Phone (Mobile)>>	Email:<<Patient Demographics:E-mail>>	
Age:<<Patient Demographics:Age>>	Indigenous/CALD status:<<Indigenous/CALD status?>>	
Aboriginal and or Torres Strait Islander:<<Patient Demographics:ATSI>>	CALD  background: <<CALD background?>>	
Country of birth:<<Patient Demographics:Country of Birth>>	Preferred language:<<Pt preferred language>>	
Medicare card no:<<Patient Demographics:Medicare Number>>	Medicare expiry date:<<Patient Demographics:Medicare Expiry Date>>	

REFERRING MEDICAL OFFICER'S DETAILS	
Family Name::<<Referring medical officer family name>>	Given Name: <<Referring medical officer first name>>	
Organisation/practice name: <<Referring medical officer org>>	Provider number:<<Referring medical officer provider no.>>	
Address: <<Referring medical officer address>>	Post code:<<Referring medical officer postcode>>	
Phone:<<Referring medical officer phone no.>>	Fax: <<Referring medical officer fax>>	
Email:<<Referring medical officer email>>		

NOMINATED GENERAL PRACTITIONER'S DETAILS 	
Family Name:<<Doctor:Name>>	Email:<<Doctor:E-mail>>	
Organisation/practice name:: <<GP practice name>>	Provider number:<<Doctor:Prescriber Number>>	
Address:<<Doctor:Address>>	Post code:<<Doctor:Postcode>>	
Phone:<<Doctor:Phone>>	Fax: <<Doctor:Fax>>	

Will the patient require prior approval from an insurer to attend a clinic: 
Reason for referral. Please tick the relevant box(es)	
All reasonable investigations have been completed	<<All reasonable investigations completed>>	
Reasonable and accessible management in the primary care sector has been tried wtih insufficient success	<<Reasonable/accessible management has been trie>>	
Pain has significant impact on life
- Sleep, self-care or pain necessitating the assitance of others
- Pain impacting on mobility, work or school attendance, recreation, relationships and/or emotions	<<Pain has significant impact on life>>	
Pain exacerbations have resulted in an Emergency Department presentation or hospital admission	<<Pain exacerbations resulted in ED/Hosp presentati>>	
There seem to be complex psychosocial influences relating to pain behaviour requiring specialised assessment and care	<<Psychosocial influences relating to pain behaviour>>	
Current or past history of addiction or prescribed medication use seem to be complicating current management; e.g. escalating opioid requirement 	<<Current or past history of addiction>>	

PATIENT DETAILS	
Difficult to control neuropathic pain is suspected 	<<Difficult to control neuropathic pain is suspected>>	
Difficult to control cancer pain	<<Difficult to control cancer pain>>	
Persistent pain following trauma or surgery where there is concern regarding transition to chronic pain
		
Location of Pain	<<Location of pain>>	
Impact of Pain	<<Impact of pain>>	
Priority category (see Referral Guide)	<<Priority cateogry >>	

PATIENT HISTORY 	
Relevant Clinical history  	

<<Clinical Details:History List>>

	
Background surgical and imaging history	<<Background surgical and imaging history>>	
Current treatment from other specialist or allied health service providers for the same pain problem?	

<<Current treatment from other specialists?>>
	
Aware and supportive of referral?	<<Other specialists supportive of referral?>>	
Please provide details	
<<Details of other specialists>>
	
History of assessment by another pain service or rehabilitation service for pain management in the last 2 years		
Name of service	<<Name of any other pain treatment service>>	
Current medication 	

<<Clinical Details:Medication List>>

	
Allergies/Adverse reactions	<<Clinical Details:Allergies/Adverse Reactions>>	
Psychiatric history?	<<Pyschiatric history?>>	
Please describe psychiatric history	<<Describe psychiatric history>>	
Have any addictions been invovled?	<<Addictions>>	
Could the patient have difficult accessing information/services?		
Impaired cognitive function?	<<Impaired cognitive function?>>	
Visual or hearing impairment?	<<Visual or hearing impairment?>>	
Difficulty reading and or accessing forms?	<<Difficulty reading or accessing forms?>>	
Difficulty travelling?	<<Difficulty travelling?>>	
Further comments on information accessibility	<<Further comments on info accessibility>>	
Has the patient consented to the referral?	<<Pt consent for referral?>>	
Does the patient require an advocate/parent/guardian to be involved in consulations and management?	<<Patient require advocate/parent/guardian?>>	
If yes: 
Relationship to patient
Name:
Contact details:
Has carer strain been identified?	<<Guardian relationship to pt>>
<<Guardian name>>
<<Guardian contact details>>
<<Carer strain?>>	
Would you like the relevant pain service to contact you for telephone advice as soon as practical?	<<relevant pain service to contact you for phone adv >>	

Referral to parallel services such as Addiction Medicine, Psychiatry and Mental health may be essential 
Thank you for your time in completing this referral

Name of person completing this form: <<Name of person completing form>>	
Date:<<Miscellaneous:Date>>	

Designation: <<Person completing this form designation>>	
Referral to: <<Referral to>>