Chronic Pain Self-Management Program Workshop Registration

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Chronic Pain Self-Management Program (CPSMP) is an evidence based program developed by Stanford University as a tool to help people with chronic health conditions. Classes are highly participatory. Mutual support in the group builds participants’ ability and confidence to manage their chronic pain.

Anyone with chronic pain or helping to care for a person with chronic pain is welcomed to participate, with the following requirements:
1. Commitment to attend all 6 classes online
2. Be interactive in class
3. Do the homework after each class
4. Fill out all the required forms

Workshop Timing: Jan 6 - Feb 10, 2022; Every Thursday, 3:00-5:30 PM for six weeks

JOIN US and Live a Healthy Life with Chronic Pain!
We look forward to meeting you!

Contact Hsiaoyin Chen-LMSW at (301) 820-7200 ext 8205 or GAAP@ccacc-dc.org for any questions.

Email *

First Name *

Last Name *

Sex *

Female

Male

Date of Birth *

YYYY

Phone *

Address *

Street Address, Apt/Unit #, City, State, Zip Code

What is the highest grade or year of school you completed? *

Some elementary, middle, or high school

High school graduate or GED

Some college or technical school

College 4 years or more

Are you of Hispanic, Latino, or Spanish origin? *

Yes

What is your race? Mark all that apply. *

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or other Pacific Islander

White

Required

Have you ever served in the military? *

Yes

What health insurance do you have? Please check all that apply: *

Medicare

Medicaid or Medical Assistance

Veteran’s or VA

Private

No Insurance

Other:

Required

Do you (or the person you are taking care of) suffer from pain that has lasted more than 3 months? *

Yes

Where is your pain? *

Head or Neck (head, neck, skull, forehead, nose, base of skull, mouth, eyes)

Thorax (armpit, ribs, shoulder, breast, chest, shoulder blade, breastbone, backbone)

Abdomen (Abdomen, buttocks, bend of hip, lower back, area between hipbones, area between anus and external genitalia, genitals, end of vertebral column)

Upper extremity (Forearm, inner elbow, upper arm, wrist, elbow, fingers/toes, hand, palm)

Lower extremity (Shin, front of lower leg, thigh, front of knee, foot, arch of foot, back of knee, calf, back of lower leg, ankle)

Required

Rate your pain on the average *

No Pain

Pain as bad as you can imagine

Rate your pain that you have right now *

No Pain

Pain as bad as you can imagine

How the pain has interfered with your: *

0 Does not interfere

10 Completely interferes

General Activity

Mood

Walking Ability

Normal Work

Relations with Other People

Sleep

Enjoyment of Life

At this time, how confident are you that you can manage your chronic pain? *

Not at all confident

Totally confident

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