Our program is not appropriate for all patients with chronic pain. Before submitting a referral, please make sure your patient meets the following criteria:

• Patient is 10 to 17 years old and has a primary chronic pain condition and severe functional disability
• Patient has completed a diagnostic work-up and is cleared for participation in physical activities for all medical conditions
• Patient has participated in outpatient pain-focused behavioral/psychological therapy
• Patient has participated in outpatient physical/occupational therapy
• Patient and family are motivated and willing to engage in a functional approach (they are not seeking additional procedure or medical solution to pain)

We require a referral from a healthcare provider prior to scheduling an appointment. Providers should make a referral by faxing a Specialty Services Form—available at the link below—along with the following. Please select “Chronic Pain Management-FIRST program” when completing the form.

• Insurance information including phone number (clear copy of front and back of card)
• Medical records from all relevant providers whom the child has seen, past and present
• MRIs or X-rays disc, labs and reports, if applicable
• A letter of medical necessity

Once all information has been received and reviewed, we will contact the family to schedule the initial evaluation. There are instances when insurance carriers may require a prior authorization before patients can be seen.