Practitioner Referral Form

Partnering with healthcare professionals to support patient wellbeing through evidence-based hypnotherapy.

Thank you for referring your client to Leanne Kerrison - Advanced Clinical Hypnotherapy.

This form is for GPs, psychologists, and allied health professionals who wish to refer clients for clinical hypnotherapy.
All information is handled confidentially and clients will be contacted within 48 hours.

Referring Practitioner Details

Practitioner Name *

Referral Practitioner Email *

Profession / Role *

Phone Number *

Clinic / Practice *

please add your workplace details

Patient Details

Full Name *

Date of birth *

Patient Email *

Other

Additional Clinical Notes

Referral Goals

What outcomes would you like this referral to support? *

Consent & Collaboration *

I confirm the client has consented to this referral and sharing of information with Leanne Kerrison for care coordination.

With client consent, I am happy to receive brief progress updates.