This form may be used to communicate with your Hypnotherapist, Our Administrative and Billing Department, and our Technical Department. When you choose the staff member, listed below, the form will be routed directly to your specified provider or department. Keep in mind that this form is secure, based on our website’s security. However, it is not directly connected to our Electronic Health Record (EHR) software. The email will be sent directly to the staff member that you’ve chosen, though information from this form may be accessed by staff members that have a valid, medical or mental health reason to access the information. When xompleting this form, we recommend including Protected health Information (PHI) such as Date of Birth, direct diagnosis information, and any other information that you would not want to share with another member of our team. If you need to speak with your provider about your care, and do not wish to use this form, simply send an email to your provider and request contact to obtain the information that you’d like to share.