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

Your name *

The referrer completing this checklist

Your email *

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. Step 2 also draws on published research to give you a quick read on how much these factors, together, may raise the chance of the pain sticking around.

High pain & medication use

High stress levels

Poor support network

Money or resource worries

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

Likelihood this pain becomes long-term (greater than 90 days) Select a factor

Based on patterns seen in published research, not a diagnosis or a clinical score — it's here to help you prioritise, not to decide eligibility on its own.

This tool is not a substitute for clinical judgement or the mandatory eligibility checklist steps. Weighting overlay has been built from Dunn et al. (2024, PLOS ONE) and Mekonnen et al. (2024, J Occup Rehabil).

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.

Participant name

First and last name

Participant email

Where we'll send the appointment details

Phone number

Best number to reach the participant

Insurer

Name of the participant's insurer

Claim number

Insurer claim reference

Date ceased work

MM / DD / YYYY

Diagnosis

Primary diagnosis as documented by the treating practitioner

Case manager name

Who is managing this claim

Case manager email

For updates on this referral

Participant eligibility checklist