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CLIENT NOTES:

Client Status

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CLIENT INFORMATION

PREFERRED NAME:

Jess

DATE OF BIRTH:

June 10, 1988

PHONE NUMBER:

9784735518

ADDRESS:

77 Main St, North Chelmsford, MA 01863, USA

EMERGENCY CONTACT NAME & NUMBER:

Josh

+1 (978) 430-7331

RELATIONSHIP STATUS:

Partner

OCCUPATION:

Counselor

How did you hear about us?

Online

HEALTH INFORMATION

Are you being treated or have you ever been treated for any psychiatric illness? If yes, please explain briefly.

Yes, PTSD, anxiety, depression, insomnia, disordered eating, SUD (alcohol) in recovery

Have you ever seen a counselor, psychotherapist, or psychologist for any issue? If yes, please explain.

Yes above stated

Are you currently taking any prescribed medication? If yes, please list.

Yes, Lexapro, zertec, Contrave, Oxybutinin

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

Yes, I am a combat veteran that spent 7 months in Afghanistan. I was attacked by a friend, and I was bullied after I got an undiagnosed brain injury.

ADDICTIONS:

None or N/A

ANXIETY

Stress, Fears, Phobias, Panic Attacks, Guilt, Trouble Relaxing

EATING PROBLEMS

Food/Diet, Weight Problems

DEPRESSION

Motivation, Procrastination, Self Sabotage, Sleep Problems

CAREER ISSUES

Memory

CONCEPTION PROBLEMS

None or N/A

PAIN CONTROL

Mobility, Inflammation, Chronic Pain

RELATIONSHIPS

DIABETES

None or N/A

Have you ever had serious thoughts of harming yourself or others?

Yes, myself

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 want to work on continuing positive trajectory for weight loss. I want to not self sabotage the positive improvements. I want to work on sustainable stretching and general exercise routine.

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

Extending enjoying the moment to food that’s in front of me. To work on energy to continue good habits, and to not look for dopamine rushes in food.

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

Yes, diets programs, gastrointestinal balloon. I am currently in medication for Wait loss and I realized I have food noice and don’t get full until stuffed without the medication. I didn’t understand what “I am saving room for dessert” means I thought it was a figure of speech until meds.even with the balloon I didn’t feel full until stuffed.

EXPECTATIONS:

Seeing what happens.

Anything else I should know?

I don’t think so

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?

190-200 lbs (bouncing between 190-200 lbs during regular ups and downs of the month)

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

2013.

What is the heaviest and lightest you have ever been?

150 lightest (extremely ill) - 250 or 260 heaviest

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

To have a more casual relationship with food- to not turn to it when I am having the feelings — to be able to have my set snacks and meals and not dream about food when I miss out.

In the military I had to maintain a certain waste measurement (34.5 in max) I was called fat even at 150 and my ribs were sticking out and sick. I was always called fat in the military. I restricted. I also would not eat to get drunker faster. I would workout A LOT and not take the calories needed. When I was out of the military I said F U and this was the first time I was in America for 5 1/2 year - I binged and did not care about my weight. I am now in a good place with my body image but want to be 200 LBs for long term health care f joints and other stuff.

Can you leave food or throw it away?

Currently yes becouse I can feel full before I am stuffed - I grew up in the clean plate club and I have moved away from that club however it’s very hard when I am not in meds.

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

Yes but have worked to find alternatives but still fall to food

Do you use food to comfort yourself?

Yes but have worked to fall to alternatives instead still fall to food

Do you have good and bad days?

If this is related to eating I work to not feel shame or guilt any longer. I don’t track calories because when I do and “fail” I spiral and feel like a deep failure of unimaginable depths - I have gone down to the point of wanting to die by suicide when “fail at the goal” when I track calories or food - so I don’t. In “good days” back when I restricted I still felt like crap and secondly dreamed of food. Good or bad I felt like garbage just in different ways.

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?

Yes- we also had a consume it now or it’s gone household.

Were any foods forbidden to you growing up?

No but comments were made

Do you prefer to cook or eat out?

Ilike to eat at home- eating out for soecal occasions. I CANNOT cook - my partner cooks 99% of the meals- we enjoy eating homemade food or ordering in (2 ish times a month)

24-Hour Recall

Christmas Eve but a general weekend day too…7 ish - omelet with peppers and cheese toco souse- 800 am Eggnog latte (normally coffee is at home with almond milk and brown sugar)……. 12 noon GF crackers and cheese, apple , kimchi.. Christmas chocolate. 5 ish - coconut curry chicken on GF penne.. 7 ish Mochi …..


Weekends are coffee and 2 meals and a snark are the norm.

Is this a typical day for you?

Weekday
6-8 am coffee. 7-10 am 2 hard boiled eggs pepper and salt, 10-12 apples with hummus, 11-1 lunch (salad with protein, left over dinner, soup stews) 1-330 carrots (always carrots) and peppers, or fruit, or kimchi, yogurt, cottage cheese, sweet something, nuts, 500 600 dinner (salad we deconstruct things like tocos, fajitas, cheeseburgers ect) or meatloaf and veggies, lots of soups and stews in winter. Most nights a few pieces of chocolate or “sweet”. I am a sugar addict - the therapy has helped curb portions to 1-2 and be satisfied. The medication has stoped me from thinking of food ALL the time.

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