Self-Hypnosis Training Note

Date of Service: [date]

Start/Stop Time or Total Face-to-Face Time: [start–stop time or total minutes]

Modality: [in-person / video / phone]

Clinician: [name, credentials]

Patient Location: [location] (Only include if telehealth)

Indication

[Presenting symptom or condition targeted, functional impact, today's training focus, patient-stated goal if relevant] (Write 3–5 sentences. Do not repeat detailed history documented elsewhere.)

Safety & Consent

• Capacity: [orientation and ability to follow instructions confirmed; ability to stop on request confirmed] (If not assessed, state "Not assessed" with plan to address.)
• Contraindications/Precautions: [No contraindications identified / precaution identified and modification made]
• Consent: [obtained / declined] (Document that hypnosis was explained as a voluntary focused-attention skill; patient remains in control and can stop anytime; potential transient effects discussed.)

Intervention Taught

• Method Overview: [name and brief description of self-hypnosis method and intended purpose]
• Induction: [type used]
• Deepening: [technique used, if any]
• Therapeutic Suggestions: [categories and intended effects] (Do not transcribe full scripts.)
• Cue/Anchor for Re-entry: [word, gesture, or imagery anchor established and instructions for use]
• Re-alerting Method: [technique used]
• In-Session Practice: [number of cycles, approximate duration per cycle, support level: full guidance / partial prompts / independent]
• Barriers and Adjustments: [barrier encountered, adjustment made, outcome] (Only include if barriers occurred.)

Response & Competence

• Patient-Reported Response: [symptom rating change if provided, perceived control, comfort]
• Clinician Observations: [observable behavioral anchors such as slowed breathing, visible relaxation, reduced fidgeting] (Avoid vague terms without observable evidence.)
• Competence Demonstration: [patient verbalized steps correctly / performed self-induction with minimal support / required ongoing prompts]
• Confidence/Readiness: [0–10 rating or qualitative statement of readiness to practice at home]
• Adverse Reactions: [reaction and management] (Only include if present.)
• Competence Not Demonstrated: [explicit statement and plan to reinforce skills] (Only include if applicable.)

Plan

Home Practice Schedule (required):

• Frequency: [days per week]
• Duration: [minutes per practice]
• Timing: [when to practice]
• Protocol Version: [name or description of exact protocol to use]
• Setting: [quiet, safe location; not while driving or operating machinery]
• Tracking: [log method with date, duration, pre/post symptom rating]
• Contingency for Distress: [stop, open eyes, grounding steps, contact clinician if needed]
• Resources Provided: [audio recording / written instructions / none]

Next Session: [follow-up timing and planned focus]

Clinician Signature: [name, credentials]

Date/Time Signed: [date and time]