Physician Referral Form

Guidelines For A Physician Referral

REQUIRED FOR HYPNOTIC PAIN RELIEF
(This format may be used for all referrals.)

The referral must contain the following elements:

• Must be on doctor’s prescription pad or letterhead.

• Must state words to the effect, "Hypnotherapy is permissible for;

• __PATIENT’S NAME__,

• for the reduction or elimination of pain (Or any other purpose.)

• from; __Long Hand Diagnosis__ and __Diagnosis Code__."

• Doctor’s signature and the date.

• Additional instructions or comments encouraged.

Dear Doctor:

Giving this referral in no way implies that you are guaranteeing results. However you can help your patient to have a positive expectation, as this has been shown to improve results.¹

For a detailed explanation of Hypnotic Pain Relief or other conditions, please see the links in the left and right columns.

Best regards.

Sincerely,

E. Everett Horsley, BS, Psy.
Director, Above And Beyond Clinical Hypnosis, LLC

Reference

¹ Barling, N. R. & Raine, S. J. (2005). Some effects of hypnosis on negative affect and immune system response. Australian Journal of Clinical and Experimental Hypnosis 33 (2): p. 165