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CLIENT NOTES:

Client Status

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CLIENT INFORMATION

PREFERRED NAME:

gavin

DATE OF BIRTH:

July 7, 2002

PHONE NUMBER:

650-6543-2322

ADDRESS:

1317 west phoenix street

EMERGENCY CONTACT NAME & NUMBER:

no

no

RELATIONSHIP STATUS:

no

OCCUPATION:

no

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.

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.

no

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

no

ADDICTIONS:

ANXIETY

Stress

EATING PROBLEMS

DEPRESSION

Confidence, Self Esteem

CAREER ISSUES

None or N/A

CONCEPTION PROBLEMS

None or N/A

PAIN CONTROL

None or N/A

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?

no

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

stress relaxation confidents

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

stress relaxation

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

no

EXPECTATIONS:

try hypnosis

Anything else I should know?

try hypnosis relaxation

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?

9/1

When was the last time you were at or near this weight?

8.95

What is the heaviest and lightest you have ever been?

lightest

If you could design a relationship with food, what would it be like?

food

Can you leave food or throw it away?

no

Do you eat when you are bored, stressed or tired, or experiencing another emotion?

stressed

Do you use food to comfort yourself?

yes

Do you have good and bad days?

no

Are your eating resolutions harder to stick to when you are out with friends?

no

Were you given chocolate/cakes/trigger foods when you were growing up?

no

Were any foods forbidden to you growing up?

no

Do you prefer to cook or eat out?

cook

24-Hour Recall

at night

Is this a typical day for you?

good

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