Hypnosis Script/Recording Instructions

Patient Name: [Patient full name]    MRN: [Medical record number]    DOB: [Date of birth]    Date Created: [Date]    Author/Credentials: [Name, degree(s), license]    Related Session Date: [Date]    Script/Recording Version: [Version label] (Only include version if revised)

Clinical Context and Therapeutic Intent

[Indication and target concerns] (In 1–2 concise sentences, specify the primary indication and target concern. Note whether hypnosis is adjunct to other treatment or primary intervention. Avoid detailed psychotherapy process content.)

• Treatment Goals – Short-term: [Short-term goals]
• Treatment Goals – Long-term: [Long-term goals] (Include only if applicable)
• Tailoring constraints and considerations: [Triggers to avoid, cultural/spiritual preferences, sensory considerations, accessibility needs, other key constraints] (Include only if applicable)

Consent Documentation

Hypnosis/Self-Hypnosis Consent (Do not infer or assume consent. Document explicitly.)

• Explanation provided in plain language regarding hypnosis/self-hypnosis and intended therapeutic use: [Yes / No]
• Expected experience and foreseeable risks/limitations reviewed: [Yes / No]
• Opportunity for questions provided and questions answered: [Yes / No]
• Consent obtained: [Verbal / Written] on [Date]
• If patient is a minor or lacks capacity: [Guardian name/relationship] provided consent; patient assent: [Obtained / Not obtained / Not applicable] (Include only if applicable)

Recording Consent (Required if any recording is made.)

• What was recorded: [Clinician voice only / Clinician and patient voice / Audio and video]
• Purpose of recording: [Home practice / Reinforcement / Other]
• Storage location: [EHR media tab / Secure server / Encrypted device]
• Access permissions: [Who may access]
• Right to decline explained: [Yes / No]
• Patient instructed recording is for personal therapeutic use only and should not be shared or posted publicly: [Yes / No]
• Consent to recording obtained: [Verbal / Written] on [Date]

Recording and Delivery Details

Recording status: [No recording created / Recording created and delivered / Recording created pending delivery / Script text provided only (no audio)]

• File name/version: [File name and version label]
• File type and length: [File type, duration]
• Date recorded: [Date]
• Storage location: [Location]
• Delivery method: [Patient portal / Secure messaging / Encrypted email / Physical media]
• Date delivered: [Date] (Omit if pending; add addendum when completed. Do not mark as delivered until patient receives file.)

Script Customization Summary

• Primary therapeutic themes: [Themes used]
• Metaphors/imagery and rationale: [Imagery with brief rationale]
• Language style: [Permissive / Directive / Mixed]; [Cultural/faith considerations if applicable]
• Patient preferences incorporated: [Preferred imagery, voice pacing, terminology, music/silence preferences]
• Content intentionally excluded: [Triggers avoided] (Include only if applicable)
• Script basis: [Standard script used / Tailored script]; Modifications: [List modifications or "none"]

Script Structure

(Provide a brief outline with approximate timing.)

• Orientation/Preface [~duration]: [Intent, autonomy and safety statements]
• Induction method [~duration]: [Method used]
• Deepening technique [~duration]: [Technique used]
• Therapeutic work/suggestions [~duration]: [Key suggestion domains]
• Future pacing [~duration]: [Application to real-life contexts]
• Reorientation/Alerting [~duration]: [Steps to return to alertness]
• Closure [~duration]: [Closing statements]

Safety-critical wording documented:

• Autonomy reminder (exact wording): [Exact phrase used]
• Reorientation instruction (exact wording): [Exact phrase used]
• Post-hypnotic cue(s) (exact wording): [Exact cues] (Include only if actually delivered)
• Full script storage reference: [Location reference]

Home Use Instructions

(This section is patient-facing. Write in second person at approximately 6th–8th grade reading level.)

Setup

• Choose a safe, private, and comfortable place.
• Sit or lie down in a stable position where you can relax.
• Plan for uninterrupted time: about [recommended duration] minutes.
• Use a comfortable volume. Headphones are optional.
• Give yourself a few minutes after listening to reorient before you get up or resume activities.

Safety Warnings

• Do not listen while driving, operating machinery, cooking, bathing, or supervising children.
• Do not listen when intoxicated or overly sedated.
• If you feel distress, pause the recording and use the grounding steps below.

Recommended Schedule

• Listen [frequency] for [duration], then [taper instructions].
• Best time to listen: [Time of day or context].
• If you fall asleep while listening: [Guidance relevant to goals]

What to Expect

• Your mind may wander. You may feel relaxed, sleepy, or partly aware. This is normal.
• Success is measured by how you feel and function (for example, calmer body, better coping), not by how "deep" you think you went.

Grounding Protocol (If Needed)

1. Open your eyes and look around. Name 5 things you can see.
2. Sit up with both feet on the floor.
3. Breathe slowly. Sip water if available.
4. If you are not improving, contact your clinician. If you have an urgent safety concern, seek emergency help.

Home use recommendation: [Recommended / Not recommended]; [If not recommended, state reason and alternative plan]

Adverse Effects Reviewed

• Precautions for this patient: [Relevant precautions] (Include only if applicable)
• Potential adverse experiences discussed: [Transient dizziness, headache, emotional release, sleep disruption, distressing imagery]
• Patient instructed to stop practice and contact clinician if symptoms persist or worsen: [Yes / No]
• Contact information provided: Clinic: [Phone]; After-hours: [Instructions]
• Crisis resources provided: [Resources provided] (Include for patients with behavioral health risk factors)

Patient Understanding and Delivery Confirmation

• Recording/script delivered: [Yes / No]; [Date], [Method] (If no, state reason and plan)
• Safe use instructions provided and reviewed: [Yes / No]
• Patient understanding assessed: [Teach-back adequate / Teach-back needs reinforcement / Not performed]; Notes: [Summary]
• Patient questions addressed: [Yes / No]; [Summary if applicable]

Follow-up Plan

• Next review date/session: [Date or timeframe]
• What will be monitored: [Monitoring parameters]
• Criteria for script revision: [Revision criteria]
• Version management: [New version issued / No change]; [Instructions regarding prior versions if applicable]

(Omit fields where information is not available rather than inserting placeholders. Store verbatim script text separately as an appendix or media file and reference its location above.)