Treatment Plan (Clinical Hypnosis)

Patient Name: [Patient name]

DOB: [Date of birth]

Clinician: [Clinician name, credentials]

Plan Status: [initial / updated / addendum]

Effective Date: [Date]

Review Due Date: [Date]

Primary Indication for Hypnosis: [Brief indication statement] (If any identifier is unavailable, enter "Not available" rather than leaving blank.)

Clinical Context

[Clinical context narrative] (Write 2–4 sentences. Begin with the presenting concern or referral question. State the clinical rationale for hypnosis, such as adjunct for symptom regulation, pain coping, or procedural anxiety. Clarify the intended scope: standalone hypnosis, adjunct to psychotherapy, or integrated with medical care.)

Diagnoses

• Primary diagnosis: [Diagnosis] — [ICD-10 code]
• Secondary diagnosis: [Diagnosis] — [ICD-10 code] (Include only if relevant to treatment planning; add additional items as needed.)

(If formal diagnosis is not established, use "Diagnostic target(s):" and list target symptoms or functional impairments. If diagnosis is carried forward from prior documentation without reassessment, note: "Diagnosis per chart; not re-assessed this encounter.")

Problem List

1. Problem title: [Plain-language title (clinical label)]

   Baseline severity: [Patient-reported or clinician-rated measure with score and date] (If baseline measure not completed, note reason and plan, e.g., "Baseline measure not completed—will obtain next visit.")

   Functional impact: [How the problem affects daily functioning]

(Add additional numbered problems as needed in priority order.)

Measurement Strategy

1. Problem: [Problem title]

   • Baseline measures collected: [Measure name, score, date] (Or note "pending" with reason.)
   • Planned outcome measure(s): [Symptom scales, function scales, or condition-specific measures]
   • Administration schedule: [every session / every 4 sessions / at formal review points]
   • Response threshold: [Definition of meaningful change, e.g., "≥30% reduction from baseline" or "score decreases to mild range" or patient-defined functional milestone]
   • Plan modification triggers: [Level of non-improvement or deterioration prompting reassessment, e.g., "If scores worsen for 2 consecutive assessments, reassess formulation and consider modifying approach or adding consultation."]

(Repeat for each problem on the problem list.)

Treatment Goals

1. Problem: [Problem title]

   Patient-stated goal: "[Patient goal in quote or near-quote]"

   Clinical goal statement: [Measurable, behaviorally anchored goal with clear timeframe] (Prefer behavioral and functional endpoints; include frequency or duration targets when possible.)

   Linked outcome measure: [Name of outcome measure that will track progress]

(Repeat for each problem. If goals cannot be finalized, document: "Goals to be finalized after baseline assessment next visit.")

Treatment Approach

Hypnosis Component: [General description of clinical hypnosis approach] (Note induction style if relevant for continuity: relaxation-based, permissive/Ericksonian, focused attention. Describe therapeutic suggestion themes: safety cues, symptom modulation, coping rehearsal. Note planned progression if applicable: initial stabilization → symptom-specific work → relapse prevention.)

Adjunct Skills Training:

• [Skill to be taught and how it integrates with hypnosis sessions, e.g., diaphragmatic breathing, grounding, imagery rehearsal, coping self-talk]

(Add additional skills as needed. Omit section if no adjunct skills planned.)

Education: [Expectation-setting provided] (Note key points covered: what hypnosis is and is not, variable responsiveness as normal, active participation emphasis.)

Care Coordination: [Communication plan with other providers; medication management note; referrals recommended] (Omit if not applicable. If hypnosis is deferred pending stabilization, document criteria for initiating hypnosis.)

Session Parameters

Session type: [individual / group] | Visit length: [30 min / 45 min / 60 min / 90 min] | Frequency: [weekly / biweekly / monthly] | Planned episode duration: [single visit / 4–6 sessions / 8–12 weeks] | Taper plan: [none / weekly ×4 then biweekly ×4 / other]

Home Practice Plan

• Self-hypnosis practice: [Frequency and duration, e.g., "10 minutes daily, 5 days/week"]
• Method: [audio recording / written cues / breath + imagery protocol]
• Safety guidance: [Where not to practice; what to do if distress increases]
• Tracking method: [practice log / app / journal]

(If home practice is not assigned, document reason, e.g., "Home practice not assigned due to acute instability; focus on in-session stabilization first.")

Safety & Consent

Safety Screening: [Elements assessed: dissociation screen, psychosis/mania screen, trauma-related flooding risk, stabilization readiness]

Adverse response plan: [Grounding steps; pacing approach; pause/stop criteria] (If suicide/self-harm risk is relevant, note location of safety plan in chart rather than duplicating.)

Consent: Informed consent for hypnosis obtained. [Key elements discussed: nature and anticipated course, risks/alternatives, voluntary participation] (If separate consent form exists, note location rather than re-documenting.)

Patient Engagement

[Patient engagement narrative] (Write 2–4 sentences. Document patient's agreement and participation level in plan development. Note relevant preferences: imagery vs somatic focus, audio recording preference, language or cultural considerations to incorporate or avoid. Note barriers discussed—time, privacy, skepticism—and accommodations planned.)

Discharge Criteria & Aftercare

• Discharge criteria: [Symptom/function targets indicating readiness for discharge; skills mastery benchmarks; maintenance plan readiness indicators]
• Relapse prevention plan: [Self-hypnosis maintenance schedule; early warning signs to monitor; availability of booster sessions]
• Aftercare/referrals: [Follow-up plan and referrals if needed]

Clinician Signature

Clinician signature: _______________________ Credentials: [Credentials] Date/Time: [Date and time]

Patient acknowledgment: _______________________ (Include if required by setting. If not obtained, document reason.)