Informed Consent & Disclosure (Clinical Hypnosis)

Patient Name: [Full legal name]

Date of Birth: [DOB]

MRN: [Medical record number]

Date: [Date of discussion]

Clinician: [Name, credentials, license type]

Guardian/Representative: [Name, relationship, legal authority] (Only include this field if a surrogate is consenting; omit entirely for consenting adults.)

Participants Present: [Patient; family/support persons with names/roles if present; interpreter name/ID if used]

Capacity and Consent Authority

[Capacity assessment] (Document in plain clinical language whether the patient appears able to understand relevant information, appreciate consequences, reason about options, and communicate a choice. Do not infer capacity; if uncertain, document the uncertainty and plan—defer hypnosis, obtain consultation, or reschedule—rather than proceeding.)

[Accommodations used] (List accommodations that supported understanding: simplified language, written materials, interpreter services, visual aids, extended time, caregiver support. Omit if none needed.)

[Voluntariness] (State that the patient is choosing freely without coercion or undue influence.)

[Who provided consent and legal basis] (If consenting adult, state that the patient provided informed consent. If a surrogate consents, state the legal basis: parent/guardian of a minor, court-appointed guardian, healthcare proxy. For minors, document parent/guardian permission and the minor's assent when developmentally appropriate.)

Description of Clinical Hypnosis

[Plain-language explanation of clinical hypnosis] (Describe hypnosis as a therapeutic process using focused attention and relaxation to deliver helpful suggestions/imagery aligned with the patient's goals, within the clinician's scope of practice.)

[Misconceptions addressed] (Document clarifications provided: the patient remains in control, can pause or stop at any time, hypnosis is not mind control, and results are not guaranteed. Include any other patient-specific misconceptions discussed.)

[Session components] (Briefly describe as relevant: check-in and goal-setting; induction method; therapeutic suggestions/imagery; re-orientation and debrief; self-hypnosis teaching or between-session practice if planned.)

[Agreed safety mechanism] (Document the agreed cue to pause/stop—verbal phrase and/or hand signal—and the grounding plan if distress occurs.)

Clinical Indication and Goals

• Target symptom(s)/condition(s): [Primary concerns and relevant diagnosis or working diagnosis]
• Patient's stated reason for choosing hypnosis: [Brief direct quote as appropriate]
• Goals: [Concrete goals—symptom reduction targets, coping improvements, functional outcomes]
• Progress assessment: [Patient-report scales, diaries/logs, functional markers, clinician measures]
• Reassessment timeline: [E.g., review after 3–4 sessions]
• Role in treatment: [Standalone / Adjunct to other treatments]; [Concurrent therapies if applicable]
• Frequency/duration: [E.g., weekly for 4–6 sessions, or note that course will be individualized]
• Homework expectations: [Self-hypnosis practice, recordings, logs; expected frequency] (Omit if none planned.)
• Scope and limits discussed: [Hypnosis does not replace medical evaluation for new/worsening physical symptoms; patient should not stop prescribed medications due to hypnosis without prescriber involvement; referral/escalation plan if symptoms worsen]

Expected Benefits

• Patient-specific expected benefits: [E.g., decreased anxiety, improved pain coping, better sleep onset—tailored to indication]
• Variability discussed: [Clarify that individual responses vary; results are not guaranteed]
• Success rate discussion: [How effectiveness was framed for this patient's context] (Include only if patient asked.)

Risks and Safety Considerations

• Common transient effects: [E.g., drowsiness, dizziness, headache, nausea, temporary emotional discomfort, sleep disruption]
• Context-specific risks: [E.g., unexpected distress or abreaction, symptom exacerbation, dissociation/panic concerns, increased suggestibility] (Include only if clinically relevant based on patient history.)
• Memory-related caution: [Memory is reconstructive; hypnosis cannot reliably determine truth/accuracy of memories; treatment will avoid leading questions aimed at retrieving specific events] (Include only if work may involve autobiographical memory or trauma.)
• Screening performed: [E.g., screened for dissociation/psychosis history, stabilization status, current substance use; outcome of screening]
• Safety instructions: [Avoid driving if drowsy; what to do if distress occurs afterward; contact instructions; crisis resources provided]

(If risks were discussed generally but no patient-specific risks identified, state that explicitly.)

Alternatives

• Alternatives discussed: [E.g., CBT/ACT/exposure-based methods, medications/prescriber referral, mindfulness/relaxation training, guided imagery, biofeedback, medical evaluation, specialty referral]
• No treatment/deferral option: [Potential outcomes of deferral and availability of other options]
• Patient preference: [If patient declined/deferred hypnosis, document preference and follow-up plan]

Patient had the opportunity to ask questions and chose [hypnosis / an alternative / to defer decision].

Confidentiality and Limits

[Confidentiality protections explained] (Plain-language summary; clarify what is documented in the medical record versus separate psychotherapy notes if this setting differentiates them.)

Limits discussed: [Imminent risk to self/others; mandated reporting of abuse/neglect; court orders/subpoenas; coordination of care with other treating clinicians as authorized]

[Electronic communication] (If using portal/email/telehealth beyond scheduling, note privacy/security limitations and agreed channels. Omit if not applicable.)

Recording Permissions

(Include this section only if recording is possible, requested, or offered; otherwise omit entirely.)

• Recording type: [Audio / Video]; recorded by [clinic system / clinician / patient]
• Purpose: [Patient home practice / Clinician supervision or training / Research or quality improvement] (Use separate explicit permission for each purpose.)
• Storage and access: [Where stored, who may access, retention period]
• Right to decline/revoke: Patient may decline recording without loss of care access and may revoke permission for future recordings by [method].
• Patient-owned recordings: [If patient records on their device, note patient responsibility for safeguarding and whether clinician consents per policy] (Include only if applicable.)

Patient Understanding and Decision

• Questions asked: [Key questions from patient and brief answers provided]
• Comprehension confirmed: [Teach-back summary—patient explained in own words what hypnosis is, key risks, and their rights] (If teach-back not feasible, state reason and document alternative method used.)
• Decision: [Consented / Declined / Deferred]
• Conditions on consent: [E.g., consents to hypnosis but declines recording; consents to relaxation-focused work only; limits on topics or techniques] (Omit if none.)
• If declined or deferred: [Alternative offered and follow-up plan] (Omit if patient consented.)

Signatures

Patient/Guardian Signature: __________________________________ Date/Time: __________ (If e-signature, note method per policy.)

Clinician Attestation: I attest that the informed consent discussion occurred as documented above, the patient/guardian was given the opportunity to ask questions, and [informed consent was obtained / patient declined / patient deferred].

Clinician Signature: __________________________________ Date/Time: __________

Interpreter Attestation: [Interpreter name/ID]. I attest that the information was interpreted accurately to the best of my ability. Signature: __________ Date/Time: __________ (Include only if interpreter was used.)

Attachments: [Separate consent form, educational handout, recording instructions provided; location in chart] (Omit if none.)