Name of Client
Name of Therapist
Date
Imagery Session
Homework Assignment: Listen daily to audiotape of entire imagery session (exposure and rescripting). Record date and time of each audiotape listening session.
Record Subjective Unites of Distress: (SUDS: 0 – 100) at the beginning and end of listening to the audiotape. Also record the peak (highest) SUDS experienced while listening to the audiotape.
Self-administer the Post-Imagery Questionnaire (PIQ-A or PIQ-B) immediately after listening to the audiotape and record the total PIQ score.
DAY 1 2 3 4 5 6 7
Date and Time
SUDS Beginning
SUDS End
SUDS Peak
DAY 8 9 10 11 12 13 14
Date and Time
SUDS Beginning
SUDS End
SUDS Peak
PIQ Score (A or B)