STEPS
Chronic Pain Program
Referral Form
Please fax signed referrals to 9201 0033 or email info@blackswanhealthcom.au
Enquiries: 9201 0044
Date of referral
General Practitioner: (Stamp)
Name:
Address:
Phone no:
Fax no:
Email:
GP Signature:
Patient Details:
Name:
Gender:
 Male
 Female
Address:
Phone no:
Mobile:
DOB:
Aboriginal or TSI:  Yes  No
ELIGIBILITY
Chronic Pain ( > 3 months)
Able to participate in group education
Pain Information
Diagnosis
EXCLUSION CRITERIA
Palliative Cancer Pain
Inability to take part in group sessions
Date diagnosed
_______
Other Medical Conditions
Current treatment:
Please list current medications (or attach):
Please attach if available:
GP Management Plan
Team Care Arrangement
Black Swan Health does not require GPMP/TCA to accept patient referrals.
My GP has explained the purpose of this assessment and program and I give permission to provide and discuss my
medical information with other service providers who are contributing to my care. I understand that my medical
information will remain confidential. Some de-identified data which will not identify me, my Practice or my GP, will be
given to the Commonwealth Department of Health and Ageing to enable the program to be evaluated. Please note:
Information may be accessed by accreditation provider r for accreditation purposes only. I am aware I will be
required to attend Black Swan Health for assessment and that Black Swan is unable to provide transport to the
assessment. I am aware that I may request a copy of the Privacy and Confidentiality statement at any time.
Patient signature:
Date:
www.panoramahealth.com.au
Suite 4/137 Main Street Osborne Park WA 6017
t: 08 9201 0044 f: 08 9201 0033 e: info@panoramahealth.com.au Perth North Metro Medicare Local Ltd (ABN 25 061 985 144)
STEPS
Chronic Pain Program
Referral Form
Panorama Health Network and PNML are now taking referrals into the STEPS Chronic Pain Program.
Through the program, patients will attend a series of group education sessions over 2 days. These
sessions are run by a behavioral medicine specialist, a physiotherapist and a pain specialist. The STEPS
program is a broad approach to the management of the patient’s pain problem, with the emphasis on
involving the patient in each step of their care, by providing them with accurate information about the
management of pain.
Up to date information and advice about the most effective management strategies for chronic pain,
including medications and procedures, movement and exercise, pacing everyday activities and
approaches to pain will be presented to patients.
All patients will then be scheduled to meet with each health professional individually, as a part of the
multidisciplinary pain team, to develop a Pain Management Plan, after putting their learning from the
group sessions into practice.
This will take place approximately 4-6 weeks post STEPS program to give participants time to implement
what they have learnt. Patients will then return to their primary practitioner to discuss and implement their
Pain Management Plan.
The sessions will be located at Panorama Health Network and PNML offices.
To be eligible for referral, patients need to:
Referred with chronic pain (> 3months)
Living within the Panorama Health Network and PNML region, or visiting a GP within the
Panorama Health network and PNML region.
Suitable for participation in group education.
Agree to complete pre-entry questionnaire to assist in triaging process.
Have an English language capacity sufficient to understand the written and spoken materials
being presented; and
Be able to give voluntary, informed consent for the ongoing collection of audit data.
Exclusion Criteria
Palliative Cancer Pain
Patients who require an interpreter service
Patients who are not suitable for the group based education and skills program
Please note patients with a high dose of opioids and those with probable dominant post
herpetic neuralgia or diabetic neuropathy may be seen by the Pain Team prior to admission to the
STEPS sessions.
For further information please contact STEPS Program Manager Ben Horgan on
9208 9546 or email ben.horgan@pnml.com.au
www.panoramahealth.com.au
Suite 4/137 Main Street Osborne Park WA 6017
t: 08 9201 0044 f: 08 9201 0033 e: info@panoramahealth.com.au Perth North Metro Medicare Local Ltd (ABN 25 061 985 144)