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CLIENT NOTES:

Client Status

Your content has been submitted

CLIENT INFORMATION

PREFERRED NAME:

Bonnie

DATE OF BIRTH:

September 13, 1977

PHONE NUMBER:

6178611066

ADDRESS:

EMERGENCY CONTACT NAME & NUMBER:

Scott Leary

617-960-6056

RELATIONSHIP STATUS:

married

OCCUPATION:

teacher

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.

yes, depression and anxiety, OCD, ADD with meds. I am off all meds now. I came off SSRI in August after 20 years of use.

Have you ever seen a counselor, psychotherapist, or psychologist for any issue? If yes, please explain.

yes, same reasons as above

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.

no

ADDICTIONS:

Drinking, Compulsive Behavior

ANXIETY

Stress, Fears, Phobias, Compulsive Behavior, Guilt, Trouble Relaxing

EATING PROBLEMS

Food/Diet

DEPRESSION

Motivation, Acheiving Goals, Procrastination

CAREER ISSUES

None or N/A

CONCEPTION PROBLEMS

None or N/A

PAIN CONTROL

None or N/A

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?

fears and phobias

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

my health related fears and of death/dying

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

yes, drugs and drinking

EXPECTATIONS:

that she understand where I am coming from

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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