Events | CheshireTrauma

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When

03 Jul 2025, 13:00 – 13:20

Where

Integrating Trauma Informed Pain Psychology

Details

1. Referrer Details

First name

Last name

Company name

Phone

Relationship to Client

2. Client Details

Full Name

Date of Birth

Day

Month

Year

Phone

Multi-line address

Country/Region

Address

City

Zip / Postal code

GP Practice (optional)

Client Case Ref No

3. Clinical / Psychosocial Background

Primary reason for referral (tick all that apply)

Chronic pain

Emotional dysregulation

Trauma history

Pain flare-up/stress triggers

Sleep difficulties

Waiting for therapy

Nervous system support needed

Low engagement with current rehab

Other:

Please describe any relevant medical or psychological diagnoses: (Briefly note pain condition, trauma history if known, or any other important context)

Are there any current safety concerns? (e.g. active suicidality, risk to others, safeguarding):

Yes

If yes, please give brief details:

4. Client Suitability

Has the client consented to this referral?

Yes

Is the client able to access Zoom sessions in a quite/private space?

Yes

5. Referral Goals & Hopes

Please share what you hope this client will gain from the Rest & Restore Protocol: (e.g. calm flare-ups, increase regulation, re-engage with rehab, feel safe in body again)

6. Funding & Payment Information

Who is responsible for funding?

If none of the above then please describe below

Is a cost agreement in place?

Yes

Contact Us

Make a Referral by contacting us at the Pain Lab to learn more about our services or to embark on a collaborative partnership aimed at alleviating and restoring hope.

Tel: 07549 009018
email: enquiries-thepainlab@outlook.com

Download Our Referral Form

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