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CLIENT NOTES:

Client Status

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CLIENT INFORMATION

PREFERRED NAME:

Ashley

DATE OF BIRTH:

June 26, 1975

PHONE NUMBER:

5082726677

ADDRESS:

14 Lovers Ln, Southborough, MA 01772, USA

EMERGENCY CONTACT NAME & NUMBER:

Ar

6177337523

RELATIONSHIP STATUS:

Husband

OCCUPATION:

Self Employed

How did you hear about us?

google 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.

yes. Anxiety, migraines

Are you currently taking any prescribed medication? If yes, please list.

no

Have you experienced any traumatic life events that I should be aware of? If yes, please explain.

yes. My mother was a verbally and emotionally abuse person. My son had cancer when he was an infant, my niece subsequently died and then I got crippled with migraines that left me housebound for months

ADDICTIONS:

None or N/A

ANXIETY

Stress, Trouble Relaxing

EATING PROBLEMS

None or N/A

DEPRESSION

Self Esteem, Self Sabotage

CAREER ISSUES

None or N/A

CONCEPTION PROBLEMS

None or N/A

PAIN CONTROL

Inflammation, Chronic Pain

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?

yes

What areas of your life would you like to work on?

Tight Pelvic Floor which leads to TMJ and vice versa. Migraines.

What is the biggest challenge that you wish to work on during your session?

Hard to choose between pelvic floor and TMJ it is the chicken and the egg.

Have you tried to do anything about this before now? If so, what?

Silva Method, chronic pain coach, meditation

EXPECTATIONS:

Well, you said you guarantee your work...so I am thinking cure!

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?

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