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CLIENT NOTES:

Client Status

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?

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