Achieve the results you desire—GUARANTEED! Set up a Free Consultation to learn!
_edited.png)
Transformational Hypnosis Therapy
CLIENT NOTES:
Your content has been submitted
CLIENT INFORMATION
PREFERRED NAME:
Debbie
DATE OF BIRTH:
May 10, 1957
PHONE NUMBER:
9788219550
ADDRESS:
61 Valley St.
EMERGENCY CONTACT NAME & NUMBER:
Sara Mousseau
978-866-0458
RELATIONSHIP STATUS:
Daughter
OCCUPATION:
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.
No
Are you currently taking any prescribed medication? If yes, please list.
Doxycycline
Over counter Vitamins
Have you experienced any traumatic life events that I should be aware of? If yes, please explain.
Many many years ago I was molested and raped
ADDICTIONS:
None or N/A
ANXIETY
Lack of Confidence
EATING PROBLEMS
Food/Diet, Weight Problems, Exercise
DEPRESSION
Confidence, Self Esteem, Motivation, Acheiving Goals, Procrastination, Sleep Problems
CAREER ISSUES
Interview Skills, Public Speaking, Concentration, Exams
CONCEPTION PROBLEMS
None or N/A
PAIN CONTROL
Mobility, Inflammation, Hair Growth, Chronic Pain
RELATIONSHIPS
Childhood 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?
Yes
What areas of your life would you like to work on?
Weight, food, motivation
What is the biggest challenge that you wish to work on during your session?
Food and weight
Have you tried to do anything about this before now? If so, what?
Yes, ozempic, semaglutide, so many different diets
EXPECTATIONS:
To learn to say no to junk food and eat better. Motivation
Anything else I should know?
I don’t think so
Are you willing to commit to listening to your personalized recording everyday for at least 21 days?
Yes very
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?
180
When was the last time you were at or near this weight?
30 years ago maybe not sure exactly
What is the heaviest and lightest you have ever been?
240 heaviest, 110 in 1982
If you could design a relationship with food, what would it be like?
Eat better
Can you leave food or throw it away?
Depends on food
Do you eat when you are bored, stressed or tired, or experiencing another emotion?
Yes
Do you use food to comfort yourself?
Yes
Do you have good and bad days?
Yes
Are your eating resolutions harder to stick to when you are out with friends?
Yes
Were you given chocolate/cakes/trigger foods when you were growing up?
Yes
Were any foods forbidden to you growing up?
No
Do you prefer to cook or eat out?
Both
24-Hour Recall
Breakfast. 2 frozen pancakes coffee w/sugar and half n half
Lunch left overs from restaurant half of short rib panini some roasted potatoes
Entenminnes apple pie
Homemade Chicken pot pie dinner 5:40 pm
A few nonpareils maybe 4 dark chocolate
Breakfast this morning 2 frozen blueberry pancakes coffee w/sugar and half n half
Coconut macaroon
Is this a typical day for you?
Yes mostly mornings the same sometimes Chibani protein drinks after gym
Sometimes banana bread, or English muffins with butter and peanut butter something easy and quick. Sometimes no lunch then snack out til dinner