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Transformational Hypnosis Therapy
CLIENT NOTES:
Your content has been submitted
CLIENT INFORMATION
PREFERRED NAME:
Jennifer Fortunato
DATE OF BIRTH:
February 18, 1971
PHONE NUMBER:
9783023939
ADDRESS:
101 Moore Rd, Sudbury, MA 01776, USA
EMERGENCY CONTACT NAME & NUMBER:
Anthony
617-549-6127
RELATIONSHIP STATUS:
Married
OCCUPATION:
Personal Coach
How did you hear about us?
Referral
HEALTH INFORMATION
Are you being treated or have you ever been treated for any psychiatric illness? If yes, please explain briefly.
Have talked to psychologist, but never diagnosed with mental illness.
Have you ever seen a counselor, psychotherapist, or psychologist for any issue? If yes, please explain.
Therapy as young mother and after dad died
Are you currently taking any prescribed medication? If yes, please list.
Gabapentin, HRT
Have you experienced any traumatic life events that I should be aware of? If yes, please explain.
Sexual assault in childhood
ADDICTIONS:
None or N/A
ANXIETY
None or N/A
EATING PROBLEMS
None or N/A
DEPRESSION
Sleep Problems
CAREER ISSUES
None or N/A
CONCEPTION PROBLEMS
None or N/A
PAIN CONTROL
None or N/A
RELATIONSHIPS
None or N/A
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?
Night sweats and better sleep
What is the biggest challenge that you wish to work on during your session?
Night sweats
Have you tried to do anything about this before now? If so, what?
Acupuncture, HRT
EXPECTATIONS:
I would love to see a drop in number of night sweats
Anything else I should know?
No
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?