Today's Date *

MM

DD

YYYY

Physician Name *

First Name

Last Name

Physician Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Your Name *

First Name

Last Name

Please read and agree to the following being requested from your physician.

The above client sought my services for Hypnotherapy to achieve their self improvement goals. As a Hypnotherapist, I offer vocational or avocational self-improvement, or work under referral of Doctors, Dentists or Licensed Psychotherapists, (Business and Professions Code 2908). Because one or more of the above mentioned client’s stated goals may have a possible medical etiology I am referring them to you for consultation and referral. I ask for your referral for this client, not as your endorsement of Hypnotherapy, but rather as your confirmation that you are aware of your patient’s symptoms and goals and that seeking Hypnotherapy for motivation and behavioral change would not be contraindicated for your patient. I welcome your recommendations and referral so that I may be of continued service to my client. Your prompt reply is greatly appreciated.

I agree