CLIENT NOTES:
Your content has been submitted
CLIENT INFORMATION
PREFERRED NAME:
ana
DATE OF BIRTH:
March 16, 2025
PHONE NUMBER:
9783944907
ADDRESS:
357 University Ave, Lowell, MA 01854, USA
EMERGENCY CONTACT NAME & NUMBER:
ramon
9788764318
RELATIONSHIP STATUS:
husband
OCCUPATION:
lab tech
How did you hear about us?
website
HEALTH INFORMATION
Are you being treated or have you ever been treated for any psychiatric illness? If yes, please explain briefly.
n/a
Have you ever seen a counselor, psychotherapist, or psychologist for any issue? If yes, please explain.
yes, depression during a grieving process
Are you currently taking any prescribed medication? If yes, please list.
n/a
Have you experienced any traumatic life events that I should be aware of? If yes, please explain.
no recently but I experienced a violent childhood
ADDICTIONS:
ANXIETY
Fears, Guilt, Lack of Confidence
EATING PROBLEMS
Weight Problems
DEPRESSION
Self Esteem, Acheiving Goals, Self Sabotage
CAREER ISSUES
Exams, Memory
CONCEPTION PROBLEMS
PAIN CONTROL
RELATIONSHIPS
Childhood Problems
DIABETES
Have you ever had serious thoughts of harming yourself or others?
n/a
Do you or any member of your family have a history of epilepsy?
yes, mother
Have you ever been hypnotized before?
yes
What areas of your life would you like to work on?
accomplish goals , pass exams and address weight management
What is the biggest challenge that you wish to work on during your session?
I would like to feel less anxiety and focus when I study and take exams right now I feel like all the information I read gets stuck somewhere in my brain and does not flow in any direction
Have you tried to do anything about this before now? If so, what?
yes, meditation before sleeping
EXPECTATIONS:
i had experienced hypnosis before I expect to solve this issue with a positive outcome
Anything else I should know?
n/a
Are you willing to commit to listening to your personalized recording everyday for at least 21 days?
sure
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?