Lynn Whitmire C.Ht., Ct.H.A.

810 Emerald Street. Suite 102

San Diego, Ca. 92109

advancedhypnotherapyonline.com

(858) 270-5756

(858) 274-3304 fax

To: Dr.____________________________

       Fax :___________________________

Your patient:________________________

Phone:_____________________________

Has recently sought hypnotic conditioning and suggestion for managing the pain, tension and anxiety associated  with_________________________________. Since I require a physician referral in such cases, I would appreciate your signature below, indicating your approval. Please send this form with your client or fax it to (858)274-3304. I will send progress letters for your files. Thank you for your prompt attention to this matter.

Sincerely,

Lynn Whitmire C.H.T., Ct.H.A.

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FOR THE DOCTOR

I have examined/evaluated___________________________________________

And see no contradiction to the use of hypnotic conditioning and suggestion in this case.

I have these additional comments and instructions for you: _______________________________________________________________

_______________________________________________________________

_______________________________________________________________

Dr.____________________________ Date____________________

                         Signature

Doctor’s Printed Name ____________________________________

Street Address___________________________________________

City________________________State_____Zip________________

Phone________________________Fax________________________