Client Intake, Consent & Confidentiality Agreement

Client Intake, Consent & Confidentiality Agreement

Jazzie Smith CHt
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth

MonthDayYear
Date
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What are you hoping to achieve through our sessions together?*
On a scale of 0-10, with 0 being nonexistent how would you rate thecurrent level of the issue you'd like to work on.*
Do you have any spiritual foundations or beliefs that you would like me to be aware of?*
What Modalities, if any, have you already tried to reach your goals?*
Bipolar Type 1Bipolar Type 2Boarderline Personality DisorderDissociative Identity Disorder (DID)Epilepsy, or seizure disorderSchizophreniaSuicidal ideation in the past 6 monthsOther (Describe Below)None of the Above
Please share any other medical, psychological, or emotional information you believe is relevant to your care:*

Disclosure of Services

Your initials acknowledge agreement and understanding of each term

Jasmine (Jazzie) Riley-Smith

Certified Hypnotherapist • Reiki Master • Mind-Body Practitioner

Certifications:
- Certified Hypnotherapist (AHA & IAPCP)
- Reiki Master, Level III
- Beyond Quantum Healing (BQH)
- Mental & Emotional Release Therapy Specialist
- Practitioner of Neuro-Linguistic Programming (NLP)
Continuing Education:
- AOS Mind-Body Psychology— Hypnosis Motivation Institute
- Holistic Flow Yoga — Teaching Certification
I understand that Jasmine Riley-Smith (also known as Jazzie Smith) is not a licensed physician, psychologist, or medical provider, and services are defined as alternative/complementary under Colorado law. ( Colorado Revised StatuteTitle 6 § 6-1-724 ) Hypnotherapy and holistic services do not diagnose, treat, or cure medical or mental health conditions. *
Initial
Consent to Treatment & Risks: I understand that holistic therapies and hypnotherapy are not substitutes for medical, psychiatric, or professional psychological care. No guarantees of specific results are made. I am responsible for consulting my primary care provider, psychiatrist, or mental health professional for any physical, psychological, or psychiatric conditions or concerns. Hypnosis may elicit memories that are not always accurate.*
Initial
Confidentiality & Exceptions: My sessions are confidential except in cases where there is intent to harm self/others, abuse/neglect disclosures, or a court order. Information revealed in hypnotherapy is not protected by psychotherapist-patient privilege.*
Initial
Consent for Use of Zoom & AI-Assisted Technologies: I understand that my name and spoken words may be visible to and processed by Zoom and related AI-assisted tools (such as closed captioning, note-taking, or script support) during my sessions. These technologies are used to enhance session accuracy, quality, and my overall care. No session content will be publicly shared or used outside of professional support, education, or development, and any identifying details will be changed or removed unless legally required otherwise. By initialing, I consent to the use of these technologies for the purposes described above.*
Initial
Waiver of Claims & Indemnification: I knowingly assume all risks, release and hold harmless Jasmine Riley-Smith from any and all claims, and agree all actions taken after sessions are by my own free will.*
Initial
I have informed the practitioner of all known medical, psychiatric, and physical conditions, and agree to update them with any changes.*
Initial
Recording Consent: I understand that portions of my sessions may be recorded, at my request or for my benefit (for example: guided hypnosis or meditation replays). I consent to the recording and understand that these recordings will not be shared beyond myself and the practitioner, unless I give written permission. I may request not to have any session recorded at any time.*
Initial
Waiver of Liability & Indemnification

I knowingly and freely assume all risks associated with participation in virtual hypnotherapy or holistic sessions, including any emotional or physical reactions, whether known or unknown, even if arising from the negligence of the practitioner.

I, or my representatives, release and hold harmless Jasmine Riley-Smith (also known as Jazzie Smith) from any and all claims or liability arising out of my participation.

I will comply with the stated terms and conditions and will notify the practitioner of any significant hazards or concerns immediately.

I, for myself and my heirs, assign, and hold harmless Jasmine Riley-Smith, her agents, employees, volunteers, or anyone affiliated, from any injury, disability, death, loss, or damage associated with my participation, whether arising from negligence or otherwise.
I understand a copy of this disclosure is automatically emailed to me at the address provided above, upon signature. I have read and understand the information above, including the hypnotherapist’s education, training, experience, and qualifications regarding the services to be provided.*
Initial

NoYes
Date*

MonthDayYear
Date
Name

First NameLast Name
Name of Parent / Guardian

First NameLast Name
Signature*

Clear
Minor’s Acknowledgment

I understand that I am participating in hypnotherapy sessions with the support and consent of my parent

or legal guardian.

I understand that what I share in sessions is confidential, except in situations where there is:

Intent to harm myself or others,

Evidence or disclosure of abuse or neglect, or

A court order requiring disclosure.

I understand that the purpose of hypnotherapy is to support personal growth, emotional well-being, and

self-awareness. I agree to participate willingly and to the best of my ability.
Parent / Guardian Initials
Minors Signature

Clear
Parent / Guardian Signature

Clear
Should be Empty: