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Registration and Assessment form

Personal details

Full name *

Email Address *

Phone number *

Date of birth *

Address

Street Address *

Apartment, suite, etc

City *

County/State *

Postal code / ZIP *

Country *

Other details

Occupation

Relationship status

Living situation

Do you have children? If yes, how many?

How did you hear about Caroline & Clear Spring Therapy? *

Medical history

What is the primary reason you are seeking therapy today?

Are you currently experiencing any heart problems?YesNo

Can you share more about your heart issues.

Are you currently experiencing any migraines or epilepsy?YesNo

Can you share more about these migraines or epilepsy.

Do you suffer with IBS or other gastro-intestinal issues?YesNo

Can you share more about these gut issues.

Do you have any specific fears and/or phobias?YesNo

Can you share more about these fears or phobias.

Are you currently using any prescription medication OR have taken or are taking any illegal drugs?YesNo

Can you share more about these medications and/or drugs.

Have you ever been diagnosed as suffering from any psychological or psychiatric condition?YesNo

Can you share more about this psychological or psychiatric condition.

Do you have any pain/tension currently AND/OR injuries you've sustained?YesNo

Can you share more about this pain and/or injuries

Do you use any disability aids (e.g. stool, cane or wheelchair) for support with particular activities?YesNo

Can you share more about these aids you use.

If appropriate, have you consulted your GP about the condition(s) for which you are seeking therapy?YesNo

General health and wellbeing

Do you have other health condition(s) that may be relevant? If yes, please give details.

Briefly describe alcohol/caffeine intake per day/week, and number of cigarettes smoked per day, if applicable.

Briefly describe your level of exercise. (Daily or weekly activities).

Briefly describe your sleep. (Trouble falling asleep? Waking during the night? Waking early?)

The information given above and throughout this form is, to the best of my knowledge, full and correct.

Payment of Fees and Cancellation Policy

Sessions are generally 75 minutes long. Please remember to switch off your mobile phone and ensure you have a quiet space where you will be uninterrupted for the duration of the session.

Fees are payable at the time of booking your session via the website.

24 hours notice of cancellation is required and credit will be given towards the next session. Failure to provide adequate notice will result in paying in full for the missed session.

Confidentiality Contract

All information whether verbal or written notes is treated as strictly private and confidential.

As a Therapist I carry responsibility to both the client and the community at large. Some moral and legal limitations therefore apply to confidentiality. These limitations mainly concern risk of serious self-harm, harm to others and child protection issues. If a situation arises in which the moral or legal limits are exceeded the reasons will be explained to you and discussed at the time.

Professional Registration

I have a professional Diploma in Cognitive Behavioural Hypnotherapy having trained with the UK College of Hypnosis and Hypnotherapy(UKCHH). The College is accredited by the NCFE who is also the awarding body.

I carry full professional indemnity and public liability insurance and I am registered with the National Council of Integrated Psychotherapists and the General Hypnotherapy Council.

I am also supervised by a qualified clinical Supervisor from the UKCHH.

Client Satisfaction

The client undertakes therapy on the understanding that it is a collaborative process in which success cannot be guaranteed and progress depends in part on the motivation and participation of the client. You have the right to access the official procedures of the NCIP in circumstances where an issue cannot be satisfactorily resolved within the bounds of our therapeutic relationship.

Unless you specifically request otherwise, a follow-up questionnaire will be sent to you, after the conclusion of treatment. This is simply to monitor outcomes and help evaluate the service provided.