Form cover
Page 1 of 1

Transpersonal Hypnotherapy Client Intake Form

Portal Within Healing Caroline Thomoff, CCHT Transpersonal Hypnotherapy, Beyond Quantum Healing, LMT, Energy work, and Sound healing Practitioner Virtual Sessions * Colorado * +1 (303)-319-9071, cthomoff7117@hotmail.com

What is your name?

Date:

Preferred nickname to be called?

Pronoun:

What is your best contact phone number?

Is it okay to leave a message on this number?

Is it okay to text this number?

What is your email?

Is it ok to receive correspondence at this email?

Mailing address:

City:

State:

Zipcode:

Birthdate:

Please check what applies:

Please check what applies:

Are you a military veteran?

Who is your emergency contact and phone number?

Do you have prior experience with hypnosis? Do you have prior experience with a meditation practice?

What brings you to hypnotherapy? If there is more than one dominant reason, list them by priority.

If you are receiving a Quantum Consciousness session/ Past Life Regression/ Life Between Lives session, please include an intention you are thinking about for the session. Please also list questions to bring forth in the session.

 In a few words, how will your life change if you get what you want?

Are you currently in other counseling?

Prior counseling dates:

List all medications you are presently taking and for what reason:

Do you have any chronic pain, recurring body aches, or chronic medical conditions?

Please share any present or past alcohol and/or drug history.

 Do you have suicidal thoughts?

What is your relationship like with your family?

Who loves and supports you in life now? This includes any pets.

What is your spiritual and or religious background? Do you draw from this background in daily life?

Do you work with guides, power animals, benevolent beings, arc-angels, or a higher source?

What stops you from having what you want?

What energizes you or what makes you feel stronger and clearer? For example: service, empowering others, wealth, making people feel like they matter, self-care, being in nature, exercise, meditation.

In a world of limitless possibilities, what would you like to create?

How did you hear about me/Who referred you?

Is there anything else you would like me to know?

Thank you for taking the time to answer these confidential questions. It will support us in moving towards your goals more easily.

Colorado Disclosure Statement

The following disclosure is provided in accordance with Colorado law for unlicensed practitioners offering complementary and alternative health care services.

1. Caroline Thomoff, CCHT is a Certified Clinical Hypnotherapist and practitioner of Transpersonal Hypnotherapy, Beyond Quantum Healing, Energy Healing, Sound Therapy, Therapeutic Massage, Breathwork, and related integrative modalities. She is not a licensed physician, psychologist, or mental health provider, and is not qualified to diagnose, treat, or prescribe for physical or mental illness.

2. The services offered are considered complementary and alternative healing practices and are not a substitute for licensed medical, psychological, or psychiatric care.

3. Caroline Thomoff received hypnotherapy training through the HCH Institute, one of the first hypnotherapy schools in the United States. Additional training includes yoga, sound healing, breathwork, energy work, and other spiritual and somatic modalities. Certifications and training are available upon request.

4. Services may include hypnotherapy, regression work, spiritual exploration, energy balancing, body-centered therapies, and intuitive healing for purposes such as personal growth, self-awareness, stress reduction, emotional processing, trauma support, spiritual development, and life-purpose exploration. These services are educational, experiential, and self-directed in nature. Any condition outside the scope of this practice will be referred to an appropriately licensed professional.

5. It is the intention of Portal Within Healing / Caroline Thomoff, CCHT to provide a safe, compassionate, and non-judgmental space for self-exploration and transformation. All services are offered through an empowerment model in which clients remain fully responsible for their own healing process, with Caroline Thomoff serving as a supportive guide and facilitator.

I have read and understand this disclosure and consent to receive services as described above.

Please sign that you acknowledge the Colorado disclosure statement:

Signature

Please date the signature:

Portal Within Healing/Caroline Thomoff, CCHT

Confidentiality & Safety Notice

All information shared during sessions is treated as confidential and held with care and respect. However, confidentiality may be limited if disclosure is required by law, including situations involving risk of harm to yourself or others, or suspected abuse or neglect of a minor, elder, or dependent adult.

If such a situation arises, it will be handled with as much compassion, transparency, and care as possible.

Online Conferencing Session Disclosure

There are potential benefits and risks of video-conferencing limits to client confidentiality that differ from in-person sessions.

• Confidentiality still applies for on-line services, and nobody will record the session without the permission from both the client and hypnotherapist.

• We agree to use the video-conferencing Zoom platform selected for our virtual sessions, and the hypnotherapist will send the zoom link just prior to your scheduled session.

• You need to use a computer, or smartphone during the session.

• You need to remain visible (on camera).

• It is important to be in a quiet, private space that is free of distractions (including cell phone or other devices) during the session. Headphones with microphone and a turned up volume can be particularly helpful for sound clarity.

• It is important to be seated or semi-reclined, as comfortably as possible, with your head well supported.

• It is important to use a secure internet connection rather than public/free Wi-Fi. It is your responsibility to use an internet connection that fully satisfies your own requirements for confidentiality. The hypnotherapist will use private Wi-Fi unless otherwise indicated in advance, but provides no guarantee to the security of the connection.

• It is important to be on time. If you need to cancel or change your online appointment, you must notify me in advance by phone or email, observing the 24 hr. cancellation policy, and 15-minute tardiness reschedule policy. 

• We need a back-up plan (e.g., phone number where you can be reached) to restart the session or to reschedule it, in the event of technical problems.

• We need a safety plan that includes at least one emergency contact, and the closest emergency room to your location, in the event of a crisis situation.

By Signing Below, I Indicate That I Have Read, Understand and Accept This Disclosure.

Signature

Date:

Portal Within Healing / Caroline Thomoff, CCHT

Waiver and Release Form

I hereby understand and acknowledge that my participation in Hypnotherapy, EFT, NLP, Brainspotting, Bi-Lateral Stimulation, Spirit Releasement, Past Life Regression, Life between lives, Quantum Consciousness, or other Energy work through Caroline Thomoff CCHT, whether at an office, in a virtual setting, or in a chosen location for which facilities are being used for my session, may expose me to many inherent risks, including accidents, injury, illness, or even death. I assume all risk of injuries associated with participation including, but not limited to, falls, contact with other participants, effects of treatment, the effects of weather, including high heat and/or humidity, and all other such risks being known and appreciated by me. I hereby acknowledge my responsibility in communicating any physical or psychological concerns that might conflict with participation in agreed-to sessions. This is a complete and irrevocable release of liability. Specifically, and without limitation, I, on behalf of myself, hereby release Caroline Thomoff, CCHT from any liability, claim, or cause of action arising out of my participation in Hypnotherapy, EFT, NLP, Brainspotting, Bi-Lateral Stimulation, Spirit Releasement, Past Life Regression, Life between lives, Quantum Consciousness, other Energy work, or arising out of Caroline Thomoff’s unforeseeable negligence. I, on behalf of myself, covenant not to pursue legal action against Caroline Thomoff, CCHT for any alleged liabilities, claims, or causes of action released hereunder. I further agree to indemnify and hold harmless and defend Caroline Thomoff, CCHT from any and all claims resulting from injuries or illness (including death), damages, or loss, including but not limited to attorneys’ fees, sustained by me or arising out of, connected with, or in any ways associated with my participation in Hypnotherapy, EFT, NLP, Brainspotting, Bi-Lateral Stimulation, Spirit Releasement, Past Life Regression, Life between lives, Quantum Consciousness, other Energy work. In the event of any emergency, I authorize Caroline Thomoff, CCHT to secure from any licensed hospital, physician and/or medical personnel any treatment deemed necessary for my immediate care, and I agree that I will be responsible for payment of any and all medical services rendered. After having read this waiver and knowing these facts, and in consideration of acceptance of my participation, I agree, for myself and anyone entitled to act on my behalf, to hold harmless, waive and release Caroline Thomoff, CCHT and any participating practitioners, officers, agents, employees, organizers, representatives, volunteers, and successors from any responsibility, liabilities, demands, or claims of any kind arising out of my participation in my participation in Hypnotherapy, EFT, NLP, Brainspotting, Bi-Lateral Stimulation, Spirit Releasement, Past Life Regression, Life between lives, Quantum Consciousness, other Energy work, or any other activities that are part of Caroline Thomoff’s programs and/or events. By my signature I indicate that I have read and understand this Waiver of Liability. I am aware that this is a waiver and a release of liability, and I voluntarily agree to these terms.

Please sign that you acknowledge this waver and release form:

Signature

Please date:

Portal Within Healing / Caroline Thomoff, CCHT

Informed Consent Form Regarding Recovered Memories

Research has found that memories uncovered during hypnosis, or other forms of induced altered states, may not be accurate or even factual. Memory is a constructive and reconstructive process. What is remembered about an event is shaped by what was observed, by conditions prevailing during attempts to remember, and by events occurring between observation and the attempted remembering. Memories can be altered, deleted, and created by events that occur during and after the time of encoding, during the period of memory storage, and during attempts at retrieval. Memories that occur either spontaneously or following the use of special procedures in therapy may be accurate, inaccurate, fabricated, or a fixture of these. This suggests that any memory uncovered during a hypnosis session be considered a possible construct of mental process, and not necessarily an actual event. Therefore, in the event that during the course of hypnotherapy, memories should surface that may be considered grounds for future litigation, you may lose your legal right to use this information in a court of law, as it would not be admissible. If it should occur that certain types of memories begin surfacing during the session with Caroline Thomoff, CCHT, the session will be discussed so that you may decide whether or not to proceed further with the hypnosis, based on your understanding and careful consideration of the above information. I have read and understood this disclosure, and I agree to participate in hypnotherapy with Caroline Thomoff, CCHT.

Please sign you acknowledge the informed consent regarding recovered memories:

Signature

Please date:

Payment 

Both Online and in person sessions can be paid via Venmo, Zelle, PayPal or Transfer Wise. For in person sessions you may bring cash! 

Note: 

Online Sessions require prepayment before we begin the session. 

Cancellation fees may be charged. 

Appointments must be canceled at least 24 hours in advance. If an appointment is canceled with less than 24 hours notice, and I am able to fill that appointment, there will be no charge. If not, there will be no charge the first time. After that, the normal fee will be charged. 

If an appointment is forgotten (a client does not come or call) there will be no charge for the first visit. After that, the normal fee will be charged.  

Late Policy: 

Upon notice, I am willing to wait for up to 15 minutes after the starting time of your appointment. If you are late, your session may be shortened in order to accommodate others whose appointments follow yours. Regardless of the length of the treatment actually given, you will be financially responsible for the full session. If you do not give notice of you running late, your appointment may be cancelled. If you arrive past the 15 minute grace period, your appointment will be cancelled. 

_____________________.

I understand that you are human and unanticipated events happen. My goal is to work with you in the most compassionate way. 

Please sign that you understand the payment and late/cancelation policy:

Signature

Please date:


Finally, remember that I am always interested in hearing from you in the future and encourage you to send me a message or leave feedback on my review page. 

With love, 

Caroline