SELF HYPNOSIS / GUIDED IMAGERY INSTRUCTION
Patient’s name diagnosis
This patient has been examined by me and is referred to Action Hypnosis Resources
Center for Professional Self Hypnosis Guided Imagery Instruction (CPT Code 90880) for the purpose of:
_____ weight reduction /management
_____ smoking cessation
_____ stress management
_____ pain management (chronic, cancer, other)
Self Hypnosis / Guided Imagery Instruction is NOT contraindicated for the condition
of this patient.
office telephone number
patient will be required to sign the attached release stating they agree and understand Self Hypnosis / Guided Imagery Instruction
is neither a replacement nor a substitute for medical treatment and will be encouraged to continue any medical treatments
/ medications they are directed to use by their Physician. Medical hypnosis / hypnotherapy treatments or sessions ARE
NOT done at Action Hypnosis Resources Center. Patients needing those types of treatments / sessions are referred to
appropriately trained professionals.
William C. Smith, BCH, CI -- Action Hypnosis Resources Center 214-754-0021 or email@example.com to set up your appointment
PATIENT RELEASE I _________________________________________, do
hereby agree and understand:
Self Hypnosis / Guided Imagery Instruction is neither a replacement nor a substitute for medical treatment.
* I agree NOT to discontinue medical treatments, medication, or Physician
visits without approval of my Physician
I will immediately discontinue the use of Self Hypnosis / Guided Imagery Instruction if directed by my Physician.
* I also agree to authorize releasing any and all hypnosis session information
(pertaining to this referral) to the referring Physician.
name _________________________ Date of referral ___ / ___ / ___ Date of first session ___ / ___ /
___ / ___ / ___
Client printed name
___ / ___ / ___
Hypnotist printed name