Client’s Name:

wishes to use hypnosis and coaching to assist in management of this current medical or emotional concern:



Since I always require the health-care provider to make a referral in such cases, I would appreciate your signature below, indicating that your patient has informed you of the decision to try hypnosis to assist in reduction of the medical or emotional concern. Please be assured that I will keep you informed if you so wish as to your patient’s responsiveness. If you think for any reason hypnosis is not appropriate in this case, please indicate below.

I am a Consulting Hypnotist in good standing with the National Guild of Hypnotists 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.

It is my goal to assist my clients in techniques that are designed to heighten their own levels of healing to increase their responsiveness to accepted medical treatments and medications.

Thank you for your kind attention.

David Gruben
Consulting Hypnotist


I have examined/evaluated this person, my patient, and I see no contradiction to the use of hypnosis and coaching in this case, if if my patient so wishes and agrees to use hypnosis to help manage the above-listed concern.

I have these additional comments and instructions for the hypnotist:




[  ] Please keep me informed of the patient’s progress.

Provider’s Name and Title:                                                                                                          

Street Address:                                                                                                                         

City, State, ZIP:                                                                                                                         

Phone:                                                                   Fax:                                                             


Success with hypnosis is dependent on many variables, including your attitude as a client, your follow-through, your adherence to the program, and your personal health and history. Please consult your physician before beginning any health program.

A consulting hypnotist can and will teach you techniques that can help you manage the everyday, ordinary problems we all have. FRMS Hypnosis does not diagnose, treat, or prescribe for any psychological or medical disorders. If you suffer from a psychological or medical disorder, please consult your physician or mental-healthcare professional.