Hypnotherapy Session Note (Chronic Pain)

Date of Service: [Date]

Session #: [Number]

Start/Stop Time: [Start time]–[Stop time]; Total face-to-face minutes: [Minutes]

Setting: [in-person / telehealth]

Telehealth confirmation: [Patient identity and location verified; privacy and safety confirmed; consent obtained] (Include only if telehealth)

Clinician: [Name, credentials]

Subjective

[Pain course since last session, including flares, triggers, and changes in baseline; current pain intensity (0–10); typical/average pain (0–10); pre-session pain rating (0–10) if measuring acute session effect]

• Functional interference: [Summary across relevant domains such as general activity, sleep, work, mobility; standardized measure scores if used] (If key domains were not assessed, indicate "not assessed" with brief reason.)
• Patient-centered functional goals (1–3):
  • [Goal in patient's own words] — [Progress since last session] — [Next-step target]
  • [Additional goals as applicable using same format]
• Self-hypnosis practice: [Practice frequency; perceived benefit or barriers] (Include only if previously assigned)
• Patient quote: "[Short quote capturing lived pain experience]" (Include only if clinically illustrative)

Objective

[General appearance; distress level; engagement and ability to follow hypnosis instructions; any safety-relevant observations such as sedation, confusion, or dissociative symptoms] (Omit this section entirely if no clinically relevant observations. For telehealth with no concerns, a single line such as "Alert, oriented, engaged, no acute distress" is sufficient.)

Intervention

• Education/consent: [Confirmation that hypnosis was explained and consent obtained] (First session only)
• Induction: [Method used]
• Deepening: [Strategy used]
• Therapeutic suggestions: [Analgesia and coping suggestions provided; targeted domains such as sensory modulation, attention shifting, relaxation, imagery]
• Post-hypnotic cues/anchors: [Cue established and intended context for use]
• Self-hypnosis training: [Technique taught and practice instructions provided]
• Duration: [Minutes of hypnosis-focused work]
• Modifications: [Reason hypnosis was shortened, modified, or stopped] (Include only if applicable)

Assessment

Safety and appropriateness: [Capacity and willingness to participate; risk screening results for suicidal ideation, severe psychiatric symptoms, intoxication; adverse events since last session; actions taken if concerns identified] (If any safety item was not assessed, state "not assessed" with rationale.)

Clinical synthesis: [Primary pain problem; current severity and interference; response to today's session including post-session pain rating (0–10) and patient-reported changes in affect or perceived control; trajectory across treatment course; clinical rationale linking intervention to symptoms and goals] (Do not infer pain reduction without patient-reported ratings.)

Plan

• Self-hypnosis homework: [Technique; frequency; barriers addressed]
• Functional goal steps: [Concrete micro-steps for next interval tied to patient's stated goals]
• Next session focus: [Planned techniques or skills to reinforce]
• Care coordination: [Communications with other clinicians; referrals] (Include only if applicable)
• Safety plan: [Steps and crisis resources] (Include only if indicated)
• Follow-up: [Next appointment; if no changes to overall care plan, state "continue current plan" with at least one specific next step]

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

Supervisor Co-Signature: [Name, credentials, date/time] (Include if required by policy)