MEDICAL REFERRAL FORM FOR CLINICAL HYPNOTHERAPY
Patient Information
Patient Name: _________________________________ Date of Birth: _________________________________ Address: ______________________________________ City, State, ZIP Code: ___________________________ Phone Number: ________________________________ Email Address: ________________________________
Referring Physician Information
Referring Physician Name: __________________________ License Number:__________________________ Address: _________________________________________ __________________________________
City, State, ZIP Code: _____________________________ ________ ________________________
Phone Number: _________________________________ Email Address:_________________________________
Clinical Information
Primary Diagnosis (ICD-10 Code): ______________________ (e.g., F41.1 Generalized Anxiety Disorder, F45.0 Somatization Disorder)
Reason for Referral: ☐ Stress Management ☐ Anxiety Relief ☐ Insomnia Treatment ☐ Pain Management ☐ Trauma Recovery ☐ Behavioral Change (e.g., smoking cessation, weight loss) ☐ Other: _____________________________________________________________________________________________
Duration of Referral: ☐ 4 Sessions ☐ 6 Sessions ☐ 8 Sessions ☐ Other: __________________________
Additional Comments or Instructions: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Recommended CPT Codes for Clinical Hypnotherapy
- 90880 – Hypnotherapy
- 96152 – Health and Behavior Intervention
- (Please confirm these codes with your insurance or practitioner, as coverage may vary.)
Physician’s Signature and Authorization
I certify that I am referring the above-named patient for clinical hypnotherapy.
Physician’s Signature: ____________________________________________________________________________ Date:______________________________________________
For Practitioner Use Only
Scheduled Appointment Date/Time: ____________________________________________________________
Clinician Name:___________________________________________________________________________________
Clinician Contact Information: __________________________________________________________________