Hypnotherapy Session Note (DAP)

Date of Service: [Date]

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

Modality: [in-person / video / audio-only]

Patient: [Patient name or identifier]

Others Present: [Name(s) and role(s) / None]

Clinician: [Name, credentials]

Diagnosis/Focus: [Primary diagnosis and/or presenting focus]

Data

(Document session-specific, factual information. Clearly distinguish patient-reported information from clinician observations. Use explicit notation such as "Not assessed (reason)" when high-salience information is unavailable.)

• Interval history: [Symptom changes since last session, notable events/stressors, home practice adherence and effects] (Label as patient-reported.)
• Today's session target: [Agreed focus/goal for this session]
• Clinician observations: [Appearance, affect, behavior, engagement] (Objective observations only.)
• Hypnosis: [performed / not performed]
  • (If performed) Induction/deepening: [Methods used]
  • (If performed) Therapeutic suggestions/imagery: [Themes and therapeutic targets at summary level] (Avoid verbatim scripts.)
  • (If performed) Trance responsiveness: [Observed indicators of absorption; patient feedback]
  • (If performed) Emergence: [Method used]
  • (If performed) Adverse reactions: [None / Description and management provided]
  • (If not performed) Alternate interventions: [Non-hypnosis interventions completed]
  • (If applicable) Imagery/memory-like content: [Description] (Document as patient experience without asserting factual accuracy.)
• Consent status: [Obtained / Previously obtained and reconfirmed / Not indicated today]
• Safety screening: [Denies acute safety concerns / Endorses concerns: (describe and note actions taken) / Not assessed (reason)]

Assessment

(Provide clinical interpretation based on today's data.)

• Symptom trajectory: [improved / stable / worsened] – [Brief rationale referencing today's data]
• Response to hypnotherapy: [Immediate effects, anticipated carryover, barriers encountered]
• Formulation update: [New or revised conceptualization / No update indicated]
• Risk level: [low / moderate / high] (Include rationale and protective/risk factors if concerns present.)

Plan

• Next session focus: [Planned target(s) and anticipated techniques]
• Home practice: [What to practice, frequency, what to track, and guidance if distress arises during practice]
• Coordination/referrals: [Consultations, collateral contacts, or referrals / None indicated]
• Follow-up: [Date/time or timeframe and modality]

Clinician Signature: [Signature, credentials]

Date/Time Signed: [Date, time]