Hypnotherapy Intake Assessment

Date of Service: [Date]

Start/Stop Time: [Start time – Stop time]

Location/Setting: [outpatient / inpatient / telehealth / other]

Modality: [in-person / video / phone]

Clinician Name and Credentials: [Name, degree(s), license]

Patient Name: [Patient full name]

DOB: [MM/DD/YYYY]

MRN: [Medical record number]

Participants Present: [Patient alone / patient with family or guardian; releases on file: yes/no]

Referral Source: [Referring clinician or agency] (Only include if applicable)

Information Sources: [Sources of clinical information: patient report, records reviewed, collateral contacts; note historian reliability if limited]

Chief Concern & Goals

[Chief concern in patient's words] (Include a brief direct quote when helpful)

[Patient-stated goals for hypnotherapy—what they want to be different if treatment helps; note priority ranking if multiple concerns]

History of Presenting Problem

[Clinically coherent narrative covering: onset and course with precipitating events; frequency, duration, and severity; triggers and maintaining factors; associated symptoms across domains such as sleep, mood, anxiety, pain, trauma; prior self-management attempts including mind-body practices; and recent escalation or crises if any] (If multiple distinct problems are targeted, organize by problem using subsections below; otherwise document as a single narrative paragraph)

[Problem Name]

[Narrative for this problem: onset, course, frequency, severity, triggers, associated symptoms, prior self-management, recent changes]

(Repeat problem subsection only if multiple distinct problems are targeted for hypnotherapy)

Functional Impact: [Impact on work/school, relationships, self-care, sleep, and daily functioning]

Relevant History

Past Treatment

• [Prior psychotherapy: modality, duration, response]
• [Prior hypnosis or hypnotherapy experience, response, and any adverse reactions]
• [Current and past psychiatric medications with response]
• [Complementary approaches tried and response: meditation, biofeedback, acupuncture, etc.]
• [Psychiatric hospitalizations or higher level of care] (Include only if applicable)

Psychiatric History

• [Prior diagnoses] (Distinguish patient-reported vs clinician-confirmed)
• [Key symptom domains assessed: depression, anxiety, panic, OCD, trauma, dissociation, psychosis-spectrum, mania/hypomania, eating disorders]
• [History of self-harm or suicide attempts with dates and details if available]
• [Relevant neurodevelopmental history] (Include only if pertinent to attention or imagery capacity)

Medical History

• [Pertinent medical conditions, especially neurologic, chronic pain, and sleep disorders]
• [Current medications and supplements]
• [Substance use: caffeine, nicotine, alcohol, cannabis, other—type, amount, frequency]
• [Sleep concerns: apnea risk, nightmares, parasomnias]

(If clinician is non-medical, note that medical history is per patient report and coordination with PCP is advised)

Family History

• [Mental health conditions, substance use disorders, and suicide history in first-degree relatives]
• [Major medical conditions relevant to the presenting problem]

(If not assessed, state "not assessed" with rationale and plan to obtain)

Psychosocial Context

• [Living situation and relationship supports]
• [Occupation/school and current stressors]
• [Legal, financial, or housing stressors]
• [Cultural or spiritual factors affecting comfort with hypnosis or explanatory model]
• [Strengths and coping resources]

Baseline Measures

• [Measure name]: [Score] ([Severity interpretation]) — Tracks: [Target problem/goal]; Reassessment: [Cadence]

(Repeat for each measure administered; if measures were not administered, note why and plan to obtain)

Risk & Safety Assessment

Suicide Risk

• Ideation: [denied / endorsed / not assessed] (If endorsed, include frequency, recency, and context)
• Plan: [denied / endorsed / not assessed] (If endorsed, include specificity and lethality)
• Intent: [denied / endorsed / not assessed]
• Access to means: [denied / endorsed / not assessed] (Note means counseling if discussed)
• Past attempts/self-harm: [denied / endorsed / not assessed] (Include dates, methods, medical severity if endorsed)
• Protective factors: [Protective factors identified or state limited/none]

Homicide/Violence Risk

• Ideation/Threats: [denied / endorsed / not assessed] (If endorsed, include target, intent, access, context)
• History of violence: [denied / endorsed / not assessed]

Overall Risk Stratification: [low / moderate / high] — [Brief rationale]

Mitigation Plan: [Safety planning steps, means restriction counseling, crisis resources provided, supports engaged] (Include only if risk is elevated)

Level of Care: [Outpatient / urgent care / ED evaluation / higher level of care] — Follow-up: [Interval and contingency instructions]

Mental Status Examination

• Appearance/Behavior: [Observations]
• Speech: [Rate, volume, prosody]
• Mood/Affect: [Mood stated; affect observed—range, reactivity, congruence]
• Thought Process: [Coherent/linear/goal-directed or abnormalities noted]
• Thought Content: [Delusions, obsessions, preoccupations; include risk content if present]
• Perception: [Hallucinations, illusions, dissociative experiences]
• Cognition/Orientation: [Alertness, orientation, attention, memory]
• Insight/Judgment: [Assessment]
• Psychomotor Activity: [Normal / agitation / retardation]
• Hypnosis-Relevant Observations: [Capacity for sustained attention; imagery/absorption observed during interview; dissociative indicators if any]

Hypnosis-Specific Assessment

Patient Understanding & Expectations

• [Patient's understanding of hypnosis and misconceptions addressed]
• [Fears or concerns expressed and how addressed]
• [Expectations for outcomes and timeframe]
• [Motivation for change]

Prior Hypnosis & Responsiveness Indicators

• [Prior hypnosis, guided imagery, or meditation experiences and responses]
• [Imagery ability and absorption tendencies per patient report]
• [Brief experiential exercise if conducted: description and observed response] (Do not assign global trait labels)

Suitability & Readiness

• [Cognitive capacity to follow suggestions]
• [Current stability: rule out acute intoxication, severe agitation]
• [Dissociation/trauma considerations: grounding capacity, window of tolerance]
• [Psychosis-spectrum or mania concerns affecting reality testing]

Suitability Determination: [appropriate / appropriate with precautions / not appropriate] — [Brief rationale]

Target Selection & Approach

• Target symptoms/behaviors: [Specific symptoms or behaviors to address with hypnosis]
• Proposed interventions: [Relaxation / imagery rehearsal / symptom modulation / ego-strengthening / self-hypnosis training / other]
• Role of hypnosis: [Primary intervention / adjunctive to other therapy]

Memory Work Safeguards: [Document that hypnotherapy is not being used to verify factual accuracy of memories; note plan to avoid leading questions with emphasis on patient autonomy and present-focused goals] (Include only if trauma or memory-focused work is planned)

Clinical Formulation & Diagnostic Impression

[Integrative formulation: predisposing, precipitating, perpetuating, and protective factors; summary of functional impairment across life domains]

Diagnoses (DSM/ICD): [Diagnoses with specifiers] (Note if provisional or deferred with rationale; distinguish patient-reported prior diagnoses from clinician-confirmed diagnoses)

Differential Considerations: [Differential diagnoses with brief rationale] (Include only if clinically relevant)

Treatment Plan

• Shared Decision-Making: [Patient agrees to hypnotherapy / declines; alternatives discussed]
• Treatment Goals: [1–3 measurable goals per problem, tied to baseline measures where available]
• Planned Interventions: [Hypnotherapy approach; adjunctive therapy components; self-hypnosis training plan]
• Session Frequency/Duration: [Frequency and estimated number of sessions]
• Between-Session Practice: [Audio recordings, rehearsal schedule, symptom diaries]
• Referrals/Coordination: [PCP, psychiatry, sleep medicine, pain clinic, other; ROI status]
• Follow-Up: [Next appointment] — Contingency Plan: [Instructions for symptom worsening]

(If patient declines hypnotherapy, document rationale, education provided, and alternative plan)

Informed Consent

• [What hypnosis is and is not; voluntary participation with ability to stop at any time]
• [Expected benefits and limitations; possibility of emotional discomfort]
• [Alternatives to hypnotherapy reviewed]
• [Confidentiality limits: harm to self/others, mandated abuse/neglect reporting]
• [Consent to behavioral health evaluation and treatment: obtained / deferred] (If deferred, note reason and that no hypnosis intervention was performed)

Clinician Signature: [Name, Credentials]   Date/Time Signed: [MM/DD/YYYY HH:MM]

(If any section was not assessed, explicitly document what was not obtained, provide rationale, and note plan to obtain. Do not assume absence of symptoms or risk without explicit assessment.)