Home Practice Plan (Hypnosis/Self-Hypnosis)

Date/Time: [Date and time of plan creation]

Patient: [Patient name and identifier]

Provider: [Name, credentials, clinic/service]

Encounter Type: [in-person / telehealth]

Contact: [Clinic phone and/or portal messaging instructions]

This plan is not for emergencies. If in crisis, see Distress Plan below.

Summary & Goals

[Plain-language summary of purpose, target symptom/behavior/goal, and timeframe] (1–3 sentences using patient-facing language)

• Patient-stated goals: [Observable goal statements as short phrases] (1–3 goals)
• Success markers: [Target frequency, intensity, or functional measures with timeframe] (If goals not finalized: "Goals to refine at next visit.")

Practice Plan

Materials Provided: [Title, length, and access location for each recording/script provided] (If none: "Patient-generated practice" or "Materials to be delivered before starting.")

Schedule: [Frequency; duration per session; preferred timing; minimum alternative if short on time] (Include brief fallback such as 1–2 minute reset if applicable)

Protocol Summary: [Setup/intention; induction method; therapeutic suggestions/imagery aligned to goal; post-hypnotic cue phrase or gesture if used; re-alerting steps; patient-specific language or cue phrases to reuse] (Keep concise. Do not include memory-retrieval directives.)

When to Use: [Primary triggers—time-based or event-based cues for practice] (Include implementation intention: "If I notice [trigger], then I will [brief practice or cue].")

Safety & Distress Plan

Do Not Practice When: Driving, operating machinery, bathing/swimming, or any situation requiring vigilance. Pause if intoxicated, significantly destabilized, or if practice reliably worsens symptoms.

If Distress Occurs During Practice:

1. Stop audio/script and open eyes
2. Orient to room (name things you see, feel feet on floor)
3. Slow exhale, sit up, use neutral grounding (water, brief walk)
4. Contact clinician if: persistent distress, panic, dissociation, intrusive imagery, worsening mood, or new symptoms

Crisis Resources: Call/text 988 for urgent emotional support. Call 911 for immediate danger or medical emergency.

Safety Review Documented: [Yes / No] — [Note on safety prerequisites reviewed and any patient-specific modifications] (e.g., eyes-open practice, avoid trauma content, shorter duration, support person nearby)

Follow-Up

Next Appointment: [Date/timeframe or "to be scheduled"]

Bring to Follow-Up: [Practice log, symptom ratings if tracking, notes on experiences or questions]

Understanding Confirmed: [Yes / No] — [Teach-back summary: key points patient articulated accurately] (Do not assume understanding; document explicitly)

Sign-Off & Attachments

Clinician Signature: [Name, credentials, date/time]

Attachments/Materials Delivered: [Item title, version date, and delivery method for each] (List all materials provided with this plan)