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Transformational Hypnosis Therapy
CLIENT NOTES:
Your content has been submitted
CLIENT INFORMATION
PREFERRED NAME:
Amy
DATE OF BIRTH:
June 23, 1982
PHONE NUMBER:
6177947585
ADDRESS:
EMERGENCY CONTACT NAME & NUMBER:
Ryan Fabrizio
339-788-7634
RELATIONSHIP STATUS:
Engaged
OCCUPATION:
Relationship Manager
How did you hear about us?
Online Search
HEALTH INFORMATION
Are you being treated or have you ever been treated for any psychiatric illness? If yes, please explain briefly.
No
Have you ever seen a counselor, psychotherapist, or psychologist for any issue? If yes, please explain.
No
Are you currently taking any prescribed medication? If yes, please list.
Yes - a series of medications related to heart disease and congestive heart failure.
Have you experienced any traumatic life events that I should be aware of? If yes, please explain.
I am divorced but it was pretty amicable. I am also a survivor of sexual assault.
ADDICTIONS:
None or N/A
ANXIETY
Stress, Fears, Phobias
EATING PROBLEMS
None or N/A
DEPRESSION
Self Esteem
CAREER ISSUES
CONCEPTION PROBLEMS
None or N/A
PAIN CONTROL
Inflammation
RELATIONSHIPS
None or N/A
DIABETES
None or N/A
Have you ever had serious thoughts of harming yourself or others?
No
Do you or any member of your family have a history of epilepsy?
No
Have you ever been hypnotized before?
No
What areas of your life would you like to work on?
I would like to overcome my fear of flying. Any benefit in other parts of my life where I get anxious due to a lack of control would be a happy secondary effect.
What is the biggest challenge that you wish to work on during your session?
Fear of flying.
Have you tried to do anything about this before now? If so, what?
Medication
EXPECTATIONS:
I just hope for some substantial improvement.
Anything else I should know?
No
Are you willing to commit to listening to your personalized recording everyday for at least 21 days?
Yes!
Are you 18 years of age or older?
Yes
AGREE TO TERMS:
I agree to all of the terms and conditions listed above.
WEIGHT CLIENTS
What is your ideal weight?
When was the last time you were at or near this weight?
What is the heaviest and lightest you have ever been?
If you could design a relationship with food, what would it be like?
Can you leave food or throw it away?
Do you eat when you are bored, stressed or tired, or experiencing another emotion?
Do you use food to comfort yourself?
Do you have good and bad days?
Are your eating resolutions harder to stick to when you are out with friends?
Were you given chocolate/cakes/trigger foods when you were growing up?
Were any foods forbidden to you growing up?
Do you prefer to cook or eat out?
24-Hour Recall
Is this a typical day for you?