Attending Physician:                                                      Date: ________________

Dr. _____________________________

Address: _________________________

_________________________________

Phone#: __________________________

To Dr. __________________:

Your patient, ___________________________________________ wishes to undergo hypnotic conditioning and suggestion for the following: (client description of situation) ______________________________________________________________________.

The Code of Ethics and Standards of the National Guild of Hypnotists requires all hypnosis for medical purposes be conducted only on a referral from a licensed physician such as you.  I conduct my practice carefully within this limit.  Your patient will be taught self-hypnosis to promote relaxation, increase comfort and self-control, and to encourage optimism.  (CPT 90880 Medical Hypnotherapy)

If there is anything further we can do to facilitate your care of your patient, please feel free to contact me.

Respectively yours,

Joseph M. Packard   M.Ed. BCH

Board Certified Hypnotherapist

 www.joe.packard.name

Date: ______________________

Mr. Joseph M. Packard

Dynamic Mind Institute

15 North Main Street C-4

Bellingham, MA 02019

508-478-8500

To Mr. Packard:

Thank you for referring: ______________________________________________

I see no contradiction to the use of hypnosis and hypnotic suggestion in this case.

I have additional comments and instructions for you:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

(CPT 90880 Medical Hypnotherapy)

________________________________

(Signature of attending physician)

Physician’s name and address:  (Please print or type)

Name: _____________________________

Address: ____________________________

____________________________________

Phone#: ______________________________

cc: client file

For the Physician:

A medical referral is requested for 2 reasons:

1. Safety

The first is to insure that the client is not in a condition that requires medical intervention prior to any other treatment.

2. Fairness

The second is that if a client is coming to our office for a condition we are unable to assist in ameliorating due to medical reasons, then they would be wasting their money for inadequate and misleading service.

This is not our intention.  Our sole intention is to assist our clients to achieve their goals in a safe and cost effective manner.

A brief explanation of what hypnosis really is …and is not.

“Hypnosis is absolutely safe.  There is no case on record reporting harmful results from its therapeutic use.”

            Rhodes, Raphael Psychologist - - Therapy Through Hypnosis

Zimbardo, Maslach, and Marshall (1972) suggest that “Hypnosis (a) is a state in which the effects of cognitive processes on bodily functioning are amplified; (b) enables the subject to perceive the focus of causality for mind body control as more internally centered and volitional; (c) is often accompanied by a heightened sense of visual imagery; and (d) can lead to intensive concentration and elimination of distractions.”

Crasilneck, Harold B., PhD and Hall, James A. M.D.

Clinical Hypnosis: Principles and Applications

According to the United States Department of Labor:

079.157.010  - Hypnotherapist

Alternate Title:  Master Hypnotist                      Alternate Title:   Hypnotist

• “Hypnotherapists induce a hypnotic state in a client to increase motivation, alter behavior or alter behavior patterns through hypnosis.
• Consults with client to determine the nature of problem.
• Prepares client to enter hypnotic states by explaining how hypnosis works and what client will experience.
• Tests subjects to determine degrees of physical and emotional suggestibility.
• Induces hypnotic techniques of hypnosis based on interpretation of results and analysis of client’s problem.
• May train client in self-hypnosis conditioning.”
• Also, “ Hypnosis is the bypass of the critical faculty of the mind and the implementation of acceptable thinking.”

Hypnosis is a tool used to help a person discover within themselves the resources necessary to accomplish their goals.  Also, this tool can be powerfully used to help clients to overcome limiting beliefs in relation to their stated objective.  In many cases, overcoming a negative belief greatly facilitates a client’s desired change.

In essence, hypnosis can greatly assist a person to powerfully and influentially communicate with themselves.

Another way of stating this is that hypnosis can only have a significant, positive impact on a person and their behavior if they desire to change and agree to engage in the change process.

Finally, the efficacy and healing power of hypnosis has been well documented by medical professionals to be safe and very real.

Hypnosis is not:

Any form of external control.  Using hypnosis, it is absolutely impossible to cause any person to do something they do not wish to do.  What is viewed upon the stage or in the movies is understood by any intelligent person, to be for entertainment purposes only.

There has never been a single case of the Rip Van Winkle syndrome whereby a person gets stuck in trance.   Also, there are no cases of a person becoming a “slave” or “zombie”.

And finally, no one revels secrets while in trance.  It is a well known fact that it is very easy to lie while in the state of hypnosis.

In conclusion:

Our minds powerfully influence our bodies.  Hypnosis is proven to give a person the ability to have a positive and very powerful effect on their health and well-being.