CLIENT NOTES:
Your content has been submitted
CLIENT INFORMATION
PREFERRED NAME:
Jan
DATE OF BIRTH:
August 12, 1963
PHONE NUMBER:
6177975656
ADDRESS:
6 Hardy Rd, Londonderry, NH 03053, USA
EMERGENCY CONTACT NAME & NUMBER:
Steve Meuse
603-490-1197
RELATIONSHIP STATUS:
Married
OCCUPATION:
currently unemployed; (had been in nonprofit music/social justice orgs - administrative/mgmt/fundraising). I am also a semi-professional violinist.
How did you hear about us?
RTT web directory
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 - I think it was coded as a general personality disorder
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.
Nothing super major, but here are a few:
-- at age 7 or 8, my sister -- who was like a second mother and primary love and affection-giver -- left home for college. I went from youngest of 4 to only child left at home with parents who were self-involved
--at age 11 sudden loss of grandfather who I was very close to
--various job losses over the years, most recently in 2023; problematic boss relationships.
ADDICTIONS:
None or N/A
ANXIETY
Stress, Fears, Lack of Confidence
EATING PROBLEMS
None or N/A
DEPRESSION
Confidence, Self Esteem, Motivation, Acheiving Goals, Procrastination, Self Sabotage
CAREER ISSUES
Interview Skills, Memory
CONCEPTION PROBLEMS
None or N/A
PAIN CONTROL
None or N/A
RELATIONSHIPS
Romantic 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?
I mentioned this in our consultation call
What is the biggest challenge that you wish to work on during your session?
Limiting beliefs that affect everything!
Have you tried to do anything about this before now? If so, what?
Various personal development programs (Landmark, Feminine Power); IFS therapy
EXPECTATIONS:
The promise of RTT combined with focused coaching. Having a compassionate, effective therapist/coach providing me a structure that I can make true progress in.
Anything else I should know?
I am eager to start asap! I also want to be sure that the agreement per this form does not negate what Stephanie and I confirmed by email regarding being able to have a full money-back guarantee if after the first month I feel I am not getting what I hoped from working with her. I am stepping into this with the expectation that I will love it, though. I am a life-long, motivated seeker of growth and development - I don't do things lightly.
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?