ABOVE and BEYOND stress, Physician Referral Form

Physician Referral Form

Guidelines for a Physician Referral.

REQUIRED FOR PAIN RELIEF

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 from;

(Long Hand Diagnosis) (Diagnosis Code)

Additional instructions or comments welcome.

Doctor’s signature and the date.

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, please see the links below.

Best regards.

Sincerely,

E. Everett Horsley, BS, Psy.

Director, ABOVE and BEYOND stress, LLC

Hypnotherapy - Because It Works

References

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