PHYSICIAN REFERRAL / APPROVAL FORM

SELF HYPNOSIS / GUIDED IMAGERY INSTRUCTION
PHYSICIAN REFERRAL / APPROVAL
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_______________________________________            ____________________________________________
Patient’s name                                                                  diagnosis (If applicable)
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)
__________________ other
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Self Hypnosis / Guided Imagery Instruction is NOT contraindicated for the condition of this patient.
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____________________________________________          _____/_____/_____
Physician’s signature                                                                      date
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____________________________________________          ______-_____-____________
Physician’s printed name                                                               office telephone number
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Each 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.
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Please contact William C. Smith, BCH, CI -- Action Hypnosis Resources Center 214-754-0021 or hypnosisrc@yahoo.com to set up your appointment
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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.
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Physician name _________________________ Date of referral ___ / ___ / ___ Date of first session ___ / ___ / ___
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__________________________     __________________________     ___ / ___ / ___
Client signature                                  Client printed name                            Date
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__________________________     __________________________    ___ / ___ / ___
Hypnotist signature                           Hypnotist printed name                    Date

Hypnosis is NOT therapy or the practice of medicine. It IS acting as a Motivational Coach to teach people the power of using their own minds to replace bad habits and ways of thinking with good, healthy ones. It can also be used to reduce stress and sleep better which can have a positive impact in helping people to be healthier. Hypnotists do not diagnose or treat patients. Hypnosis is complementary to licensed health professionals and not an alternative to them. Most of my new clients come from other satisfied clients I have worked with. I appreciate and welcome referrals from Physicians and Mental Health Professionals and also from Educators, Coaches, and other Hypnotists.

Expect, Look for, and Find something Wonderful, Fun, and Exciting – EVERY day! -- Coach William

William C. Smith, Dallas Hypnosis Board Certified Hypnotist having first cup of morning coffee

I'm a night owl. If you call BEFORE 10 AM I probably haven't had my first cup of coffee and may be grouchy and maybe not very alert.

Call today for a free phone consultation to find out if You're a good candidate for using Hypnosis in Your Life!
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Please call any day AFTER 10 AM and BEFORE 10 PM Central Time.
2 1 4 - 7 5 4 - 0 0 2 1
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When You call, You'll either get me - live in person - or my recorder. Yes, I answer my own phone. I do not use the services of a receptionist or secretary. I want to talk to You personally. If You get my recorder, please leave Your name and number. When stating Your phone number, please speak slowly, and repeat the number just in case another call comes through a nd beeps out one of the numbers. Thanks.
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Or email me at: hypnosisrc@yahoo.com

Action Coaching Resources Center
One Metro Square Professional Building
2655 Villa Creek Dallas, Texas 75234

Here's a picture of the professional office where I am located. A nice relaxing pond with a waterfall in front and a courtyard with fountains between the two wings of the building.

Dallas Fort Worth Hypnosis NLP professional office in One Metro Square

For payment, I accept: Checks or Cash -- or Credit / Debit cards – Visa / MasterCard / American Express / Discover -- I do not accept chickens, dairy products, puppies or kitties, or young children.

I do not accept insurance – IF (that’s a very big IF) Your insurance covers my services, I will be glad to give You a receipt You can turn in for any reimbursements they may give You. It’s Your responsibility to check with Your HR department or insurance company to see if they do cover my services.

PLEASE READ:
The services I render are held out to the public as non-therapeutic Hypnotism, defined as the use of Hypnosis to bring about positive thinking and the capacity for self-Hypnosis. I do not represent my services as any form of medical, behavioral or mental health care, and despite research to the contrary, by law I may make no health benefit claims for my services.
Guided Imagery and Self Hypnosis Instruction sessions, with proper Physician referrals / approvals when required, are scheduled at Action Resources Center -- Hypnosis of Dallas / Fort Worth. Medical Hypnosis / Hypnotherapy treatments or sessions are not.
Hypnosis is considered to be Complementary (working with your Physician or Medical Care Provider) - as opposed to Alternative Medicine (instead of).
There are many reasons and conditions a Physician may refer you for Hypnosis. The most common are Weight Reduction, Smoking Cessation, and Stress Management. But there are many other reasons as well.
Hypnosis, used in conjunction with the care of your Physician can be a powerful tool to enhance your wellness and help with dealing with the stresses of disease, illness, and injuries. It can help you have a healthier and happier life.
The services I offer are not meant to be substitutes for psychological or professional counseling services. If you have an ongoing mental health problem, please consult a professional licensed by your state.
Drug and alcohol addiction work is NOT done at Action Hypnosis Resources Center. By law in Texas, these situations MUST be referred to a Licensed Chemical Dependency Counselor.