CLIENT NOTES:
Your content has been submitted
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