Health Care Professional Referal Form

Joe Packard, Board Certified Hypnotist
Dynamic Mind Institute
37 Monique Drive, Bellingham, MA 02019
508-478-8500
www.joepackard.com         joe@joepackard.com

Physician/Health Care Referral
Dear Dr. ________________________________________
I, Joe Packard, am a trained and board certified hypnotist by The National Guild of Hypnotist. I complete annual continuing education to maintain my proficiencies at the highest level and in accordance to the rules and regulations of The National Guild of Hypnotists, I have an established private practice in hypnotism, and my business Dynamic Mind Institute is located in Bellingham, MA.
Your patient: _____________________________________________________________________
and/or parent/guardian: __________________________________________________________
has requested my help and assistance in the area of: _________________________________________
Hypnotism is not at this time licensed by state governments, and is a self-regulating profession of certified practitioners. I am neither a physician nor a licensed health care
provider, and I do not provide medical diagnosis or medical treatment for illness, disease or mental disorders of any kind. Hypnotism does not replace conventional medical
procedures, but works as a complement and in conjunction with the health care system.
Hypnotism is a mental conditioning process that allows the above named patient to use the natural and normal faculties of their mind to create desired and positive change and
health in their life.
Your signature below authorizes me to help and guide the above named patient through the techniques of hypnosis for the purpose described above.
Thank you.
Joe Packard, BCH
Date:
Physician Signature: ______________________________________________________ Date:_______________________
Physician Telephone Number: ________________________________________________________________________
Physician Address: ____________________________________________________________________
_______________________________________________________________________
Patient Signature: ________________________________________________________ Date:__________________________
Parent or Guardian Signature (for patient under 18 yrs. of age): _________________________________________
Date: _____________________________

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