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Transformational Hypnosis Therapy
CLIENT NOTES:
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?