810 Emerald Street. Suite 102
San Diego, Ca. 92109
Physician Fax: ________________________________________________
Patient Phone: ________________________________________________
Dear Dr. ____________________________________________________
I am a certified Mind-Body Hypnotherapist with a private practice in San Diego and a member of the International Medical and Dental Hypnotherapy Association. Your patient has requested help in managing fear, tension and anxiety surrounding their___________________________________________________________________________________________.
I do not attempt to treat or diagnose disease or mental disorders of any kind. Hypnosis in no way replaces standard medical procedures, but complements them by freeing the patient of feelings and attitudes that may be inhibiting their response to them. Through hypnosis, one uses the natural mental faculties of the mind to create a positive attitude allowing the patient to make the most of the medical help available. Hypnosis creates a strong positive expectancy and reduces stress, thereby normalizing the action of the autonomic nervous system.
Since I require a physician referral in such cases, your signature below, indicating your approval, allows me to help your patient to increase their own natural resources through visualization and progressive relaxation. Please send this form with your client or fax it to (858) 483-3223. Thank you for your prompt attention to this matter.
Lynn Whitmire C.H.T.
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. Signature.___________________________________________________________________ Date__________________
Doctor’s Printed Name __________________________________________________________________________________