Medical Referral Form

NLP Hypnosis Centre. Medical Referral Form.

Dear Health Care Provider: 

I have been contacted by your patient requesting instruction in Self-Hypnosis and Consulting Hypnotism.. It is my policy to be sure that the attending physician or other health care provider is aware that the patient is practicing hypnotism and will likely experience less worry and discomfort than other patients. 

Research suggests there may be other general health benefits as well. Consulting Hypnotism is motivational coaching by means of hypnotism and is not considered health care. Therefore, health insurance does not normally cover hypnotism and your patient will be paying me directly for my services. 

If you have any objection to your patient receiving hypnotism would you please inform me. If there is anything in particular you would like to include in my work with your patient, please let me know. 

I am a NGH Consulting Hypnotist and a NGH Certified Hypnosis Instructor,  NGH Board Certified, in good standing with the National Guild of Hypnotists Inc. (NGH) and my continuing education is current. I practice in accordance with the Code of Ethics, Standards of Practice and Recommended Terminology of the National Guild of Hypnotists, and give every client a comprehensive Client Bill of Rights which fully discloses my training and practice limits. 

My business, NLP Hypnosis Centre, is registered in Ontario and I follow Ontario's laws and regulations. 

Please feel free to learn more about my services and background from my web sites and/or

Your patient:______________________________________________________________________________________________
and/or parent/guardian________________________________________________________________ has requested my help and assistance in the area of: _____________________________________________________________________________. 

Your signature below authorizes me to help and guide the below named patient through the techniques of hypnosis for the purpose described above. 

Please include your address and telephone number, so that with your request I may inform you of your patient’s progress. Please feel free to call me at 519-495-6405 if you have any questions. 

Physician Signature:____________________________________________________________ Date:____________________ 

Physician Telephone Number _____________________________ 

Physician Address: ______________________________________________________________________________ 

Patient Full Name:_________________________________________________________________________________________

Patient Signature:_______________________________________________________________ 


Parent or Guardian Signature (for patient under 18 yrs. of age): __________________________________ 

Date: ___________________________ 


Olivier Hidalgo.
NGH Certified Consulting Hypnotist,
NGH Certified Hypnosis Instructor.
NGH Board Certified.

Member of National Guild of Hypnotists, NLP Global Standards 
and International Society of Hypnosis (Spain).
NLP Hypnosis Centre.
151B York Street, London, Ontario. N6A 1A8