Referral to the Pain Management programme

Referring OT's details

Name *

Phone

Email *

Date

Client's details

Name *

First

Last

Date of birth

Email *

Sex

Male
Female

Phone

Next of kin name

Next of kin phone

How regular are your sessions and can you foresee being able to facilitate the homework tasks with the client weekly? Or do we need to look at another way of doing this (we can discuss)?

Has the client consented to a referral being made to this group and is aware of their commitment to attend each week?

Yes
No

Internet Access

Can the client access zoom independently?

Yes
No

If not, who will provide support?

Can the client access a printer?

Yes
No

Would they (potentially) benefit from 1.1. session with Garry for IT support?

Can the client attend the group independently or will they need a support worker/family member to be present?

Can the client sustain concentration/attention for an hour session on a zoom call?

Any specific communication needs?

Sight
Hearing
Speech

Communication needs details?

Key Programme Areas and Issues

Please provide a list of the key information relating to the client – as relevant to their participation in the group. (Pippa will be given access to file so can then read more – as required).

Rehabilitate Therapy LTD

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