Miscellaneous Information (Chapter 16: Kissing Frogs)

Chaplain Paul G. Durbin, Ph.D. 

CHAPTER 16: MISCELLANEOUS INFORMATION:

(1) Durbin Inducted Into International Hypnosis Hall of Fame:

(2) Disappointment Becomes A Blessing: 

(3) Managing Stress: Advertisement: 

(4) Smoke Free Facility Letter By Mr. Fred Young:

(5) Letter to Physicians Concerning Hypnosis:

(6) Stop Smoking With Hypnosis: Advertisement: 

(7) "Hypnotist Teaches Students To Relax": Nunez Community College:

(8) Four Brain Wave Patterns: 

(9) Visual, Auditory, Kinesthetic:

(10) The Dark Mile: Coming Through A Bad Experience: 

(11) Buddha And The Man Who Wanted Deliverance:

(12) Sir Henry Vane of London and Priorities:

(13) Airplane Metaphor For Experiencing New Situations: 

(14) Overcoming Procrastination With Sleeping Well On a Windy Night: 

(15) Reimbursement form for hypnotherapy charge:

 

(1) Durbin Inducted Into International Hypnosis Hall of Fame: News Release by Joanie Kingsley 1992: Reverend Paul G. Durbin of New Orleans, Louisiana, was presented with the Hypnotherapist "SEALAH" Award at the 13th. Annual "SEALAH" Awards Dinner held during the International Hypnosis Hall of Fame Annual Conference. The honor was presented to Durbin by Penny Duton Rafa, Founder of the IHHF and Robert "Bert" Freeman, Executive Vice President of IHHF. The Awards Dinner was one of the Highlights of the conference which was held at Guest Quarters Hotel, Plymouth Meeting, Pa.

Durbin is a United Methodist Minister serving as Director of Pastoral Care at Memorial Methodist Hospital in New Orleans, La (Biography followed as of 1992)... He is consulted by medical doctors for pain management, stress management, and stop smoking for in-patients and out-patients. He also works with clients for those area plus overcoming phobias, weight control and other means of self improvement.

The IHHF presents each year the prestigious "SEALAH" Awards. The "SEALAH" Awards are presented to individuals and/or organizations for outstanding contributions and achievements. Three other nominees were selected for "SEALAH" Awards among the 18 who were proposed for these honors. In addition to Durbin, inducted were: Helen Acord who received the "SEALAH" Pioneer Award, Wendell G. Loder who received the "SEALAH" Lifetime Achievement Award, and St. John's University, Springfield, La. received the "SEALAH" Education Award accepted by University President Dr. Arthur Winkler.

(2) Disappointment Becomes A Blessing: (From Sybil Waldrop's Book, Getting Good At Being You): In the summer of 1969, Major Paul Guy Durbin, a Chaplain in the United States Army, was assigned to a unit at Fort Hood, Texas. For his year and a half as Administrative Chaplain, he received the Meritorious Service Medal. Then he was transferred to another brigade to serve as Assistant Chaplain. Someone who rated his services from personnel put a derogatory remark on his Officers Efficiency Report (OER). Six months later while in training at Walter Reed Army Hospital, Major Durbin learned about the derogatory remark in his OER. He sent a disclaimer and requested that the unjust statement be removed. He was informed that the statement would remain, but the disclaimer would be part of the report.

In 1975 while serving in Bangkok, Thailand, Durbin received word that he had been passed over for promotion to Lieutenant Colonel, the derogatory remark was the culprit. According to policy if he was passed over again in 1976, he would leave the army.

Durbin's clinical training at Walter Reed Hospital prepared him emotionally for what otherwise would have been a grave disappointment. Prior to his clinical training, Major Durbin confessed that he had an inferiority complex which he described as a feeling of "low self-worth masked over with an outgoing personality." He had what he called a conversion experience. His motivation for ministry changed from fear to love. He developed a feeling of self-worth and dignity within himself which was not dependent upon verification from others although, admittedly, that helped and still does.

Major Durbin shared his plight with the Bishop of the Louisiana Conference. In June of 1976, while attending annual conference, Major Durbin was asked if he were interested in an opening at Methodist Hospital in New Orleans beginning September 1. His clinical training at Walter Reed had prepared him for the work of hospital chaplain. Then Major Durbin received word that the military had declared the two boards had been illegally convened, and all officers passed over in 1975 and 1976 could stay on active duty until January, at which time their records would be reviewed again. Now he had a choice. Durbin chose to accept the position at Pendleton Memorial Methodist Hospital. In December of 1976, the army promotion board promoted Major Durbin to Lieutenant Colonel. He was to return to duty with his promotion date retroactive to 1975. He chose to remain at Methodist Hospital.

While continuing his work at Methodist Hospital, Major Durbin also became a chaplain in the Louisiana National Guard and was promoted to Lieutenant Colonel, and after attending staff school, he was promoted to full Colonel in 1984.

In February 1986, Colonel Durbin was informed that he was being considered for a new position as Army National Guard Special Assistant to the Army Chief of Chaplains which carried the rank of Brigadier General. In June, Durbin was selected but he could not wear the rank until federal recognition by Congress. He is now the first Brigadier General Chaplain in history of the Army National Guard. In telling me his story, the Chaplain recalled the story of Joseph. Joseph's brothers sold him into slavery and told their father that Joseph had been killed. Years passed, and a famine prompted Joseph's brothers, to travel to Egypt to get grain. Unknowing to the brothers, Joseph was in charge of Egypt's grain. The Chaplain found solace in these words, "But Joseph said to them, 'Do not be afraid, for I am in God's place. And as for you, you meant evil against me, but God meant it for good in order to bring about this present result, to preserve many people alive.'" (Gen. 50:19-20)

(3) Managing Stress: Advertisement: Wellspring Newsletter July, 1994: Stress is the body's response to a demand placed upon it. It is the tension you feel when faced with a new, unpleasant, or threatening situation. Stress can produce an automatic reaction to a danger or a demand. Muscles tighten, blood pressure rises, and heart rate increases as the body prepares itself for "fight" or "flight." Stress is also essential to life and is often considered "The spice of life." Some degree of stress can be good since it inspires you

to meet life's challenges. It is only when it becomes excessive that it can be harmful to both your physical and mental health. Instead of feeling nervous, angry, upset, or burned out; you feel calm, happy, in control, and alive by managing your stress.

Begin by doing something just for you. Do something you enjoy and set aside some time just for you. For example, take a hobby; do it with commitment - this means stick to it. You should be able to see and feel the difference.

Other things you may choose to include; physical exercise, deep breathing, self-hypnosis, and/or meditation. You may also need to get more sleep, work out anger, talk out problems, eat well, manage your time better, and take breaks. All of these suggestions imply you helping you.

STRESS MANAGEMENT: 7:00 P.M. - 8:30 P.M. Chaplain Paul G. Durbin, Ph.D.

Director of Clinical Hypnotherapy at Methodist Hospital, will explore ways of reducing stress through imagery, self-hypnosis and relaxation techniques. Lecture, discussion, and demonstration will be included (Wednesday July 13)

SELF-HELP THROUGH SELF-HYPNOSIS: 7:00 P.M. - 8:30 P.M. This program is designed to explore the methods of self-hypnosis for self-improvement. It focuses on myths as well as the positive use of hypnosis and will include demonstration and participation. Presented by Chaplain Paul G. Durbin (Wednesday July 20)

STOP SMOKING WITH HYPNOSIS: (By individual appointment)

Become a non-smoker through the use of relaxation, imagery, and hypnosis. Chaplain Paul G. Durbin will conduct individual sessions. By fee. For more information and/or reservations, call the Chaplains office - 244-5430. ("Wellspring" is the Methodist Hospital logo for community education. Stress Management and Self Hypnosis class are offered to the public each July and January. These are among the best attended classes offered by Wellspring.)

(4) Smoke Free Facility Letter By Mr. Fred Young: (President of Methodist Hospital:) [Mr Young is now CEO of Methodist Health System Foundation, affiliated with Methodist Hospital] Dear Employee: As you may be aware, Methodist Hospital will become a smoke-free facility on September 1st. The smoke-free environment includes Methodist Hospital, the Methodist Cancer Center, Methodist Ambulatory Surgery Center, Methodist Health System Foundation, Physical Medicine Center, and the Child Care Center.

The move to a smoke-free environment supports the position of the Hospital Medial Staff and the Orleans Parish Medical Society, calling for all health care facilities to eliminate opportunities for smoking. There will be two designated areas outside the facility where smoking will be allowed. The sun deck on the fourth floor near the Chapel and the gazebo in back of the hospital across from the emergency department will be designated as smoking areas. In addition, for the Methodist Cancer Center and Methodist Ambulatory Surgery Center, special areas outside these buildings will be noted.

Chaplain Paul Durbin will also conduct one-on-one hypnosis sessions to help smokers break the habit. Please contact the Chaplain's Office at extension 5430 for additional information.

As you know, smoking is a leading and proven contributing factor to heart disease, respiratory illness and lung cancer. Recent research indicates that those who do not smoke, but are in the company of heavy smokers, are just as susceptible.

As a leading health care facility and corporate citizen of New Orleans East, Methodist Hospital must set an example of a healthy environment so that others may follow. In the coming weeks, you will be learning more about the Hospital's campaign to eliminate smoking. For those of you who are smokers, I encourage you to participate in one or more of the smoking cessation programs that will be offered. Sincerely, Fred Young, President

(5) Letter to Physicians Concerning Hypnosis:

TO: Methodist Hospital Medical Staff

FROM: Chaplain Paul G. Durbin, Ph.D.

SUBJECT: Stop Smoking, Stress Management, Pain Management, Weight Control, and other self-improvement procedures through the use of relaxation, positive imagery, and hypnosis.

A number of physicians on the staff of Methodist Hospital have requested information concerning stop smoking, stress management, pain management, weight control and other self-improvement procedures. The client receives a tape on the subject which has been identified to help reinforce suggestions given during the session.

STOP SMOKING:

The Stop Smoking Program has been very successful. The program usually takes one session with a free follow-up session within 30 days if needed. (Free session is for Stop Smoking only.) The hour consists of a discussion of what hypnosis is and is not, and how hypnosis helps one overcome the smoking habit. The client's smoking history is discussed and reason why client desires to be a non-smoker. After determining the client's response patterns, the hypnosis begins with proper suggestions for being a non-smoker.

STRESS MANAGEMENT:

Stress Management for an individual may take one to several sessions. Discussion of stress factor, how to better deal with them, and progressive relaxation and self-hypnosis are taught to the client.

PAIN MANAGEMENT:

I am available upon request to teach patients progressive relaxation, positive imagery and self-hypnosis for pain management. The procedures are used in conjunction with client's medical care and requires a doctor's referral.

WEIGHT CONTROL:

In regards to the "Weight Control" Program, a doctor's referral is required. I do not provide a diet plan as I am not a dietitian or medical doctor. Three sessions for weight control counseling are required with more available if needed.

I am a Certified Clinical Hypnotherapist and a Diplomat with the National Association of Clergy Hypnotherapist, a Fellow with American Association of Professional Hypnotherapist (AAPH). I have written many articles for Professional Journals, given seminars throughout the United States on Hypnosis, and was inducted into the International Hypnosis Hall of Fame in 1992, located in Blue Bell, Pa. I received the "Pin and Quill" Award from NBHA for my book Human Trinity Hypnotherapy, in 1994.

Enclosed are copies of "Stop Smoking with Hypnosis: (Stress Management, Pain Management, and Weight Control) for your office.

(6) Stop Smoking With Hypnosis, Advertisement: (Stress Management, Pain Management, Weight Control): Chaplain Paul G. Durbin, Ph.D., Director of Clinical Hypnotherapy, Methodist Hospital, is a Certified Clinical Hypnotherapist who is available to help you overcome the smoking habit. Chaplain Durbin's "Stop Smoking with Hypnosis" Program is highly successful and usually takes one session with a free follow-up within 30 days if needed. The follow-up is for Stop Smoking only.

The hour consists of a discussion of what hypnosis is and is not and how hypnosis helps one overcome the smoking habit. The client's smoking history is discussed and reason why the client desires to be a non-smoker. After determining the client's response patterns, the hypnosis begins with proper suggestions for being a non-smoker. The client receives a booklet, "Introduction to the Value of Hypnosis" and a "Stop Smoking" audio tape to help reinforce suggestions given during the session.

For outpatient sessions fee is _____ Senior Citizens and employees receive a 50% discount

Chaplain Durbin is also available for Stress Management, Pain Management, Weight Control, Positive Imagery, and other improvement procedures. Pain Management and Weight Control requires a physician's referral.

Chaplain Durbin has written many articles for Professional Journals, presented seminars throughout the united States on Hypnosis, and was inducted in the International Hypnosis Hall of Fame in 1992, located in Blue Bell, Pa.

(7) "Hypnotist Teaches Students To Relax": Nunez Community College Article" by: Julie Landry, New Orleans Times-Picayune 1992: If the students in Paul Durbin's class at Nunez Community College in Chalmette look like they're sleeping, it's because he's doing a good job. Durbin is Chaplain and Director of Pastoral Care at Methodist Hospital in New Orleans. He started using hypnosis to treat patients with chronic pain in 1981.

In a recent class, Durbin's students paired up to wind each other down in a progressive relaxation exercise. The hypnotist wooed the student into a dreamlike state by asking him to visualize a lemon. Richard Gardache, 45, of Chalmette waved his hands dramatically as he lulled Christine Pattini, 37, of Slidell to a quiet state.

Can you see the lemon? Can you see it"? "Yes" You're visionary. That's good." he said as Prattini closed her eyes. "I want you to take three deep breaths. You're going to relax. You're going to feel peace." he said.

Prattini's legs, crossed at the ankles, relaxed slightly. The fingers on her outstretched hand rested lightly on her legs, "All your tensions are going away. Now just enjoy the sensations." he said before slowly counting her back to an alert state. "Despite the distractions," Prattini said, indicating the 20 students surrounding her in the classroom, "I did feel relaxed."

Gardacher, who served 2 years as a New Orleans Police officer, uses the relaxation techniques to relieve chronic back pain but said he could've used these skills on the job. "Sometimes we used relaxation techniques with prisoners when they got out of hand." he said.

Ginger Frolich, 43, of Chalmette suffers from chronic pain in her legs and back. She has gotten relief from being hypnotized and wants to learn the technique herself. "I usually can sleep only an hour and a half at a time," she said. "This technique refreshes you and relaxes your whole body. It's like a booster shot."

Often patients don't like to think they've been hypnotized, Durbin said. They say they feel better and are more relaxed."

In one class exercise, Durbin swung a pendulum to show students how the direction that it swung could indicate answers to questions posed to someone under hypnosis. "It's not going to tell the future and not going to give you numbers on the lottery ticket but it will help you answer questions in your subconscious mind." he said.

Durbin said some people are afraid of hypnosis because they're worried the hypnotist will make them do something against their will. "The person (under hypnosis) is in control," Durbin said. "They won't do anything against their belief system. To go under," Durbin said, "The person has to be able to think, reason, and communicate. You actually gain control, because hypnosis lets you learn more ways to improve your life."

(8) Four Brain Wave Patterns: There are four primary brain wave patterns: Beta, Alpha, Theta, and Delta. The Beta state is one of awakened physical alertness. This is the state in which we spend most of our waking time. The Alpha state brings heightened creativity and enhanced physical relaxation. The Alpha state produces hypnosis or deep meditation. Theta state is being on the brink of going to sleep. It is also a natural state of hypnosis. The Delta state is a state of light to profound sleep.

(9) Visual, Auditory, Kinesthetic:

1.Visual: They usually speak in terms of seeing or watching. Examples: "I see what you mean." "I can't see that." "Looks good." "Picture this." Visual people will give vivid descriptions of things as though painting a picture. They have a tendency to show you something as they're talking. They like to have eye contact. Typically, a visual person will use predicates such as: see, behold, observe, view, witness, look, glance, etc. When a visual person thinks, his eyes tend to move up and to the right.

2. Auditory: You can recognize an auditory person by observing the way his eyes stay level while moving right and left, down and to the left. Auditories use "sound" words to communicate and they like the sound of their own voice. Their voices have an even, rhythmic, tempo and melodious, easy-to-listen-to-sound. They use terms like: "I hear what you say." "That sounds good to me." They make lots of noise jingle coins or keys in the pocket, scuffle feet, walk loudly. They like to repeat things. If you ask them "What time is it?", they may repeat the question and then give you the answer. They laugh at the punch line and then repeat it. They don't need the eye to eye contact that visual people need. Typically an auditory person speaks using predicates such as listen, hear, take in, hark, attend, etc.

3. Kinesthetic: Kinesthetics' eyes move down and right when they are processing information. They readily express feelings about anything. They like or hate; they're hot or cold. You will hear "spaces" in kinesthetic's conversation while he takes time to check out his feelings about what is going on. The kinesthetic's voice is generally deeper than the voice of the visual or Auditories.

Kinesthetic people will talk in terms of feelings. Examples: "I can't handle this." "I can't grasp that." "I feel like a steak today." "That doesn't feel right." They have a tendency to touch a lot, and they have a need to be touched back. Typically, a kinesthetic person will use predicates such as touch, handle, feel, itch, excite, sharpen, etc.

Most people have a dominate preference but can communicate in more than one mode. Knowing a person's mode helps you to communicate more effectively with him and to gain trust and rapport quickly. To be most effective, alter your response mode to that of the client. The knowledge of the client's mode help in formulating suggestions for the client.

(10) The Dark Mile: Coming Through A Bad Experience: Dr. Richard H. Hutton told of an interesting incident that he and a companion had during a visit to Scotland. They did most of their traveling by foot. Late one afternoon, they came to a little inn where they spent the night. As they were talking to the innkeeper, he told them that the most beautiful lake in all of Scotland was only about four miles from the inn. He got a map and traced the path to the lake with his finger. The path went around in a semi-circle. Dr. Hutton asked, "Isn't there a shorter way?" The innkeeper answered, "There is a shorter way, but no one goes that way by choice. It runs through the 'dark mile' which is a fearful gorge." Dr. Hutton desired to know why it was called the "dark mile". He was told that the path through the gorge was narrow and gloomy; dark and frightening, and that big overhanging ledges of rock was dripping water all along the way.

Wanting to save time, Dr. Hutton and his friend decided to go to the lake by way of the "dark mile". They found it about as the innkeeper had described it. Though they were both fearful, they were able to keep going because they gave each other support. They slowly made their way through the dark gorge and finally they saw the light that marked the end of the "dark mile". It had been gloomy, dark and frightening, but they had make it. As they came out of the gorge, before them was beautiful Lake Lackrey. Both gasped at the sight of the beautiful lake which was surrounded by the mountains. Dr. Hutton's friend said, "I don't believe that we would ever have appreciated the beauty of the lake if we hadn't traveled the "dark mile."

Each of us must at one time or another travel the "dark mile". You may feel that you are traveling that "dark mile" right now because of this problem. Use whatever faith you have to make it through your "dark mile" to the beauty of a new direction in your life.

(11) Buddha And The Man Who Wanted Deliverance: From 1973-75, I lived in the Buddhist nation of Thailand and there is an interesting story connected with Gautama Buddha which I would like to share with you. Gautama Buddha vowed that he would die unless he could find the way of life, the path of deliverance. The story is told that after he had found what he considered the way of life, a certain man came asking Buddha to show him the way. Buddha led the man down to the river. The seeker assumed that he was to undergo some act of purification or baptism. When they were some distance out in the stream, Buddha suddenly grabbed the man and pushed his head under the water. In a last minute effort, the man pulled himself free and quickly brought his head out of the water. Buddha asked him, "When you thought you were going to drown, what did you want most?" The man gasped, "Air." Back came Buddha, "When you want deliverance as badly as you wanted air, then you will get it." It seems that what we truly want and work for, we tend to get.

(12) Sir Henry Vane of London and Priorities: As we look at our world today, we see that many have failed to get their priorities in order. Many are like Sir Henry Vane of London. Sir Henry was to have his head cut off at the executioner's block. He was given one last word. Rather than pleading for his life or making some great statements, he begged the executioner not to hit a painful boil on his neck. How ridiculous we might say for once that ax feel it did not matter what part of the neck it hit. He magnified the insignificant and overlooked the vital. How often do we magnify the insignificant and overlook the vital.

(13) Airplane Metaphor For Experiencing New Situations: When we are faced with a course of action that seems unfamiliar to us, we often think that because we have not experienced the exact situation before, we know nothing about it. In those circumstances, it may be useful to think of the situation in the same way as someone might who is about to take a trip on an airplane for the first time. He or she may think that they know nothing about it, but they may discover that know quiet a bit about it. Let's say that this person is Mr. Jones.

Mr. Jones may never have been on an airplane before, but has been on a bus. Furthermore, he has been on a bus going to different town so he knows how to read a timetable and find out about departure and arrival times. Having done that, he knows how to get in touch with the travel agency for buying tickets. He knows how to phone ahead to make sure that the plane is going to leave on time.

In the past, when he was traveling by bus, he knew how to find the right place to board the bus. He had some suitcases, so he knew how to get them to the place where they will be check for the journey. In the bus, he chatted in a comfortable, friendly way with the people sitting next to him. At the end of the journey, he know how to find the special place to pick

up the suitcases and to make his way through the bus depot where the taxis are or to meet this friends to pick him up.

Mr. Jones had never been on an airplane, but he had traveled before on commercial transportation so he could use the knowledge to help him on this trip. In fact, Mr. Jones knows almost all there is to know about traveling on an airplane except actually being on an airplane. It is just all of this information was scattered around in a variety of different experiences, and needed to be gathered up and re-applied to the new circumstances.

For this present situation in which you find yourself, ask your subconscious mind to gather up all the information it can find that may in someway relate to it... A little bit of information from that past experience, more information from another experience...And put them all together in one package...One that is useful and appropriate for the present. You know far more than you know that you know. Enjoy discovering the wonderful range of your own knowledge.

(14) Overcoming Procrastination With Sleeping Well On a Windy Night: You have made a decision to overcome procrastinating because you want to be on time and succeed in life. You expect to do things on time and you feel a sense of enthusiasm and confidence in living your new attitude toward getting things done...

You are overcoming procrastinating because you want to... You are taking a great deal of pride in the fact that you have matured... You are taking control of your life and beginning to do the things that you put off in the past... You exchange your old habit of putting it off to your new approach of getting it done. You are ready to do the unpleasant task which you used to put off doing and you feel good about yourself. You refuse to let task pile up on you anymore. You get it done...

You complete your task easily and you have confidence in yourself and abilities. You get the job done well, efficiently, and properly. You stop worrying about the job you need to do and get it done...You are pleased with yourself for doing what needs to be done. You enjoy a feeling of success in each and every task that you take on and finish. As your confidence grows, as your abilities grow, as you accomplish, more and more every day, you feel good about yourself and your self-confidence increases more and more everyday and in every way.

I share with you this story: A boy went to a farmer and asked to be given a job working on the farm. The farmer asked, "Are you willing to work?" "Yes sir, I can sleep well on a windy night." was his strange reply. "Can I trust you to look after my things?" Again the boy replied, "Yes sir, I can sleep well on a windy night." The farmer asked several questions seeking to determine if the boy was honest and trustworthy, but to each question, he got the one reply.

He decided the boy might be a little foolish, but there was something about him that the farmer liked, so he hired him. The boy proved to be a good worker and everything went well until one night a big storm came up. The farmer rushed to the boy's room. Get up," he shouted, "Let's go tie down the hay stacks, put up the tools and secure the barn door." But the boy was so sound asleep that the farmer could not wake him. Fearing to waste time trying to get him up, he rushed out to see about the things.

When he came to the hay stacks, he found them already firmly tied. He found the tools in their proper places in the barn and doors closed securely. As he went back into the house he realized what the boy had meant about sleeping well on a windy night. He meant that each day, he did as best he could and, even in the midst of the storm, he could sleep. By coming to me, you have made a commitment to overcome procrastination. You get things done so you can "sleep well on a windy night."

15. Reimbursement form for hypnotherapy charge: Physician referral required.  Client should send copy of physician referral and this form to insurance requesting reimbursement.  Most insurance will reimburse based on client's coverage.

Receipt and Statement for Insurance

Patient's Name:_______________________________ Sex________________

Address: ________________________________City: _________________________

State : ______________ Zip_________________ Phone_______________________

SS#_______________________ DOB_______________________

Insured's Name:_________________________________________

Relationship to Patient: ___________________________________

Sex: __________ Phone: ___________ D.O.B.:______________

Address: _________________ City: ________________ State_______________ Zip________

Phone: ____________ D.O.B. __________________ SS# _____________________________

Insurance Co._________________________________________________________________

Policy No. _______________ Group No. __________________ Employer:_______________

Date of onset: ______________ Date of first consultation: _____________________________

Referring Physician:________________ Address: ____________________________________

City ____________________ State: ____________ Zip: _________ Phone: _____________

 CPT Code                     Description of Service                         DMS Code          Fee           Payment

90880                 Hypnosis/Single Session IDCA943-2           300.02

Dates of service:

Total Fee:

Signature of Certified Hypnotherapist ________________________________Date: ________

(For Client to sign):

I authorize release of records if necessary to process my claim. I agree that a photocopy of this authorization is as valid as the original.

Signature: _______________________________________ Date: _____________________