CLIENT NOTES:
Your content has been submitted
CLIENT INFORMATION
PREFERRED NAME:
Jillian
DATE OF BIRTH:
December 19, 1983
PHONE NUMBER:
5085779240
ADDRESS:
5 Moseley St, Billerica, MA 01821, USA
EMERGENCY CONTACT NAME & NUMBER:
Becca Robbins
4133472120
RELATIONSHIP STATUS:
married
OCCUPATION:
human resource
How did you hear about us?
HEALTH INFORMATION
Are you being treated or have you ever been treated for any psychiatric illness? If yes, please explain briefly.
PTSD, major depression and anxiety
Have you ever seen a counselor, psychotherapist, or psychologist for any issue? If yes, please explain.
currently seeing a therapist and a psychiatric NP
Are you currently taking any prescribed medication? If yes, please list.
Zoloft
Risperidone
Trazadone
Clonidine
Naltrexone
Have you experienced any traumatic life events that I should be aware of? If yes, please explain.
several, but the most prevalent would be being left alone in a hotel room when I was 9 before we moved cross country, sexual harassment, and attempted assault in 2018/2019, significant argument with my husband in October 2019, lost my job in 2020 because I was good at what I do, but my personality wasn't for them, hospitalizing my 14-year-old in March 2024, asking for help with alcohol addiction and being told by several physicians "I can't help you"
ADDICTIONS:
Drinking
ANXIETY
Stress, Fears, Panic Attacks, Guilt, Trouble Relaxing, Lack of Confidence
EATING PROBLEMS
Food/Diet, Weight Problems
DEPRESSION
Confidence, Self Esteem, Motivation, Self Sabotage, Sleep Problems
CAREER ISSUES
Concentration, Memory
CONCEPTION PROBLEMS
None or N/A
PAIN CONTROL
Chronic Pain
RELATIONSHIPS
Childhood Problems, Peer Problems, Romantic Problems, Family Problems
DIABETES
None or N/A
Have you ever had serious thoughts of harming yourself or others?
Yes
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?
mental/emotional
What is the biggest challenge that you wish to work on during your session?
Determining what it is that is preventing me from moving forward in talk therapy, and breaking through.
Have you tried to do anything about this before now? If so, what?
Meditation, mindfulness, medication, therapy, yoga, exercise
EXPECTATIONS:
Have patience with me as talking about myself and through experiences is new to me and extremely difficult.
Anything else I should know?
I am having increasingly frequent and intensive intrusive thoughts. I am scared. Asking for help is a challenge, but I acknowledge should I do nothing the alternative would be much harsher.
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?