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CLIENT NOTES:

Client Status

Your content has been submitted

CLIENT INFORMATION

PREFERRED NAME:

Chris

DATE OF BIRTH:

April 15, 1974

PHONE NUMBER:

6033214490

ADDRESS:

24 Douglas Dr, Candia, NH 03034, USA

EMERGENCY CONTACT NAME & NUMBER:

Jacqueline Payraudeau

603–320-1690

RELATIONSHIP STATUS:

Mother

OCCUPATION:

Semi retired

How did you hear about us?

Online

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

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

Yes, Sertraline, Losinapril, Omeprazole

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

Divorce

ADDICTIONS:

ANXIETY

Stress, Guilt, Trouble Relaxing, Lack of Confidence

EATING PROBLEMS

DEPRESSION

Confidence, Self Esteem, Procrastination, Self Sabotage

CAREER ISSUES

None or N/A

CONCEPTION PROBLEMS

None or N/A

PAIN CONTROL

None or N/A

RELATIONSHIPS

Childhood 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?

No

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

Mental and emotional

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

Relationships

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

Therapy

EXPECTATIONS:

Feel better

Anything else I should know?

Yes

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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