CLIENT NOTES:
Your content has been submitted
CLIENT INFORMATION
PREFERRED NAME:
Ashleigh Peterson
DATE OF BIRTH:
June 18, 1983
PHONE NUMBER:
5086417999
ADDRESS:
350 High St, North Attleborough, MA 02760, USA
EMERGENCY CONTACT NAME & NUMBER:
Craig Peterson
774-353-6959
RELATIONSHIP STATUS:
Married
OCCUPATION:
OR RN
How did you hear about us?
HEALTH INFORMATION
Are you being treated or have you ever been treated for any psychiatric illness? If yes, please explain briefly.
Yes, treated for anxiety/depression/panic disorder
Have you ever seen a counselor, psychotherapist, or psychologist for any issue? If yes, please explain.
Yes, seeing psychiatrist. Have tried talk therapy before with no help
Are you currently taking any prescribed medication? If yes, please list.
Clonazepam 0.5mg twice day, lexapro 20mg a day, Wellbutrin 300mg XR a day, clonidine 0.2 mg at night for sleep, rexulti 0.5mg a day
Have you experienced any traumatic life events that I should be aware of? If yes, please explain.
Yes, sexual/emotional abuse in high school from boyfriend, raped by friend, married alcoholic then divorced, had major postpartum depression after childbirth
ADDICTIONS:
ANXIETY
Stress, Panic Attacks, Compulsive Behavior, Guilt, Trouble Relaxing, Lack of Confidence
EATING PROBLEMS
Exercise
DEPRESSION
Confidence, Self Esteem, Motivation, Acheiving Goals, Procrastination, Self Sabotage, Sleep Problems
CAREER ISSUES
Memory
CONCEPTION PROBLEMS
None or N/A
PAIN CONTROL
Inflammation, Chronic Pain
RELATIONSHIPS
Childhood Problems, Peer Problems, Romantic Problems, Family Problems
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?
Only casually in a show
What areas of your life would you like to work on?
Become more motivated, be able to get out of bed every morning, be able to stop avoiding work, overcome sleep difficulties, find my purpose, find out who I truly am.
What is the biggest challenge that you wish to work on during your session?
Overcome depression/lack of motivation/find out who I really am
Have you tried to do anything about this before now? If so, what?
Medications, talk therapy
EXPECTATIONS:
Gain insight to who I am, gain positive progress through program
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?