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Transformational Hypnosis Therapy
CLIENT NOTES:
Your content has been submitted
CLIENT INFORMATION
PREFERRED NAME:
Dilara
DATE OF BIRTH:
June 13, 2002
PHONE NUMBER:
7743316681
ADDRESS:
22 Gardner Ave, Lowell, MA 01854, USA
EMERGENCY CONTACT NAME & NUMBER:
Alvin Wang
9788319392
RELATIONSHIP STATUS:
Significant Other
OCCUPATION:
Bartender/Server
How did you hear about us?
Reccomendation
HEALTH INFORMATION
Are you being treated or have you ever been treated for any psychiatric illness? If yes, please explain briefly.
Just in therapy for my dissociation and panic attacks.
Have you ever seen a counselor, psychotherapist, or psychologist for any issue? If yes, please explain.
Yes. I see a therapist once every few weeks.
Are you currently taking any prescribed medication? If yes, please list.
I take Hydroxizine as needed if I feel very anxious.
Have you experienced any traumatic life events that I should be aware of? If yes, please explain.
Father with severe anger issues, bipolar disorder, and narcissistic personality disorder. Most of the reason why I am in therapy is because of him. Also would add that my mother stayed with him and is still with him despite all that he has done.
ADDICTIONS:
None or N/A
ANXIETY
Fears, Phobias, Panic Attacks
EATING PROBLEMS
None or N/A
DEPRESSION
Procrastination
CAREER ISSUES
Driving Skills
CONCEPTION PROBLEMS
None or N/A
PAIN CONTROL
None or N/A
RELATIONSHIPS
Childhood 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?
Getting rid of my panic attacks especially on planes and feeling relaxed or even excited instead of scared when I go on them.
What is the biggest challenge that you wish to work on during your session?
Getting rid of my panic attacks/anxious feelings for good.
Have you tried to do anything about this before now? If so, what?
Meditation, journaling, mindfulness practices, going on prescription medications, reading, reiki, gratitude.
EXPECTATIONS:
To cure my fear of planes and be able to go on them without having debilitating anxiety and panic attacks.
Anything else I should know?
I am also in a constant state of disassociation and I have been since 2021.
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?