Workshop Registration Form - Living Well with Chronic Pain

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Introduction

Course
  • Course: Living Well with Chronic Pain
  • Location: Online video & zoom course
  • Venue: Online
Dates
  • Start Date: 01/06/2021
  • Time: Zoom sessions: Monday's 5.15-5.45 (30 Mins)
Registration Time
  • Around 10 minutes

Before we can complete your registration, we need to ask you a few questions. These questions help us understand your situation and help us ensure you are getting the best care for your individual needs. In most cases the course you have chosen will be right, but if we think something else might be more helpful we will contact you to discuss this.

There are 7 stages to this form, stages 1 and 6 are the longest so don't be put off. It usually takes about 10 minutes to complete this form. Once started, Please do not click the back button on your browser or the form will be reset and you may have to start again. Once the form is submitted, you will receive an email confirmation.

First, some information about you:

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Personal Details

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GP Details

(These courses are offered free on the NHS and you therefore need to be registered with a local GP to access this service)

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Mood quiz (PHQ-9)

Over the last 2 weeks, how often have you been bothered by any of the following problems?

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Anxiety Quiz (GAD-7)

Over the last 2 weeks, how often have you been bothered by any of the following problems?

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Course Details

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Equality & Diversity

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Terms and Conditions

Please note: By entering your information into this course registration form, you consent to your data being entered into our (HiM) clinical information systems

Once you have submitted your form, the information you provided will be checked and you will be contacted to confirm the next steps. If for any reason we feel the course is not the most suitable treatment we offer we will contact you to discuss and carry out a more comprehensive assessment of your support needs.

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