Participant eligibility checklist

Chronic pain predictability graph

Is your participant eligible for the Amelio pain program?

A few quick questions to confirm suitability before you refer. It takes about two minutes, and we'll guide you one step at a time.

~2 minutes 3 short steps Instant result
Before you start
The referrer completing this checklist
Where we can reach you about this referral

Around 1 in 5 injuries develop into chronic pain. Research shows the likelihood is shaped less by the original diagnosis and more by a set of factors present at the time of injury. The checklist looks for these signals so the right participants reach the program early.

High pain & medication use
High stress levels
Poor support network
Low socioeconomic circumstances
Poor general health & lifestyle
Step 1 of 3 · Essential criteria

First, the essentials

All three need to be confirmed for a participant to be eligible. Choose an answer for each.

1
Over 18 years of age
participant meets the minimum age requirement.
2
Has access to internet
Able to take part in the online program.
3
Pain interferes with daily life
Pain is limiting normal day-to-day function.
Step 2 of 3 · Risk factors

What's making this pain stick?

Select every factor that applies. At least one is needed to be eligible, the more present, the more the program can help.

Selected: 0 of 6
Step 3 of 3 · Final check

Important safety check

This is the only thing that would rule a participant out, even when everything else fits.

Do not exclude for

Anxiety, depression, stress, poor sleep, or emotional distress when these are associated with the pain condition. These are exactly where the program helps.

!
Is there an active, unstable mental health condition unrelated to pain?
For example psychosis, uncontrolled bipolar disorder, or active suicidality requiring urgent intervention.
Result

participant is not the right fit at this time

Essential criteria — all confirmed
Risk factors — 0 identified
Exclusion check — none present
participant is eligible for the program. Complete for this participant only.

Participant details

A few details so we can reach out and arrange the first conversation.

First and last name
Where we'll send the appointment details
Best number to reach the participant
Name of the participant's insurer
Insurer claim reference
MM / DD / YYYY
Primary diagnosis as documented by the treating practitioner
Who is managing this claim
For updates on this referral
Amelio Health · Referral tool · For insurer & case-manager use