Hypnotherapy Session Note (Procedure-Related Anxiety)

Date: [date]
Patient: [patient name or identifier]
Provider: [name, credentials]
Session Time: [start time – stop time (total minutes)]
Modality: [in-person / telehealth]

Chief Concern & Procedure Context

[Patient-centered reason for session, including brief patient quote if available] (Include target procedure type, scheduled date if known, and setting. If details are not yet confirmed, state "unknown" rather than inferring.)

Consent & Safety

• Informed consent for clinical hypnosis: [obtained today / confirmed from prior date] (Document patient understanding that hypnosis involves focused attention and suggestion-based intervention, is an adjunct to—not a substitute for—medical sedation, and that questions were addressed.)
• Coordination permissions: [granted / declined / pending] (Specify scope for sharing coping strategies with procedural team.)
• Risk screen (suicide/homicide): [negative / positive with brief rationale and safety steps if applicable]
• Contraindications/caution flags: [none identified / identified: describe] (Include dissociation risk, psychosis, substance intoxication, or unstable medical factors as relevant. Document clinical decision: [proceed / modify approach / defer and refer].)

Subjective

[Narrative of procedure-related anxiety] (Include onset relative to procedure timeline, prior procedure experiences including any traumatic events, specific feared outcomes, avoidance behaviors, and prior coping attempts. Identify key triggers and known buffers. Include baseline anxiety rating with scale used if obtained.)

Objective

• General appearance/behavior: [observations]
• Affect: [observations]
• Engagement capacity for hypnosis: [attention, absorptive capacity, ability to follow guidance]
• Physiologic signs of anxiety: [none observed / relevant signs observed]

Assessment

[Diagnostic impression related to procedure-related anxiety] (Include severity and functional impact on procedure readiness. Provide brief formulation of maintaining factors and relevant protective factors.)

Intervention

• Psychoeducation: [content provided regarding hypnosis mechanism, expectations, and self-efficacy]
• Induction approach: [approach used] (Note rationale relative to patient needs.)
• Deepening/stabilization: [method used]
• Therapeutic suggestions: [themes addressed such as anticipatory coping, physiologic calming, control restoration, procedural imagery rehearsal] (Summarize themes without verbatim script.)
• Cue-controlled relaxation anchor: [specific cue trained] (Describe conditioning steps, in-session testing, and patient efficacy rating.)
• Emergence: [method used] (Note immediate reactions and orientation confirmed.)

Response & Plan

• Patient response: [ability to visualize and accept suggestions; notable shifts in catastrophizing or sense of control]
• Pre/post anxiety ratings: [scale and values, or "not obtained"]
• Adverse reactions: [none / describe with interventions taken]
• Procedure-day plan: [timing of cue use; communication preferences with procedural staff; contingency steps if anxiety escalates]
• Home practice: [assigned frequency; materials provided; safety reminders]
• Follow-up: [timing of next session and goals]
• Referrals/coordination: [actions taken or planned with status]

(If any information was not obtained, note explicitly with rationale rather than omitting.)

Provider Signature: [name, credentials]
Date/Time: [signature date and time]