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Transformational Hypnosis Therapy
CLIENT NOTES:
Your content has been submitted
CLIENT INFORMATION
PREFERRED NAME:
Kelly
DATE OF BIRTH:
March 14, 1970
PHONE NUMBER:
6035488906
ADDRESS:
6 Pepin Dr, Bow, NH 03304, USA
EMERGENCY CONTACT NAME & NUMBER:
Jackie Friberg
(603) 867-4018
RELATIONSHIP STATUS:
Friend
OCCUPATION:
Kitchen Designer
How did you hear about us?
HRT site
HEALTH INFORMATION
Are you being treated or have you ever been treated for any psychiatric illness? If yes, please explain briefly.
Depression in 1989nwhen I was at college and in 2006 when I started to run Ric’s business.
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.
HRT for menopause
Have you experienced any traumatic life events that I should be aware of? If yes, please explain.
Lost my mom June 2021, favorite friend June 2022, father June 2023, menopausal June 2024.
ADDICTIONS:
Drinking, Other
ANXIETY
Stress, Phobias, Panic Attacks, Lack of Confidence
EATING PROBLEMS
None or N/A
DEPRESSION
Acheiving Goals
CAREER ISSUES
Memory
CONCEPTION PROBLEMS
None or N/A
PAIN CONTROL
None or N/A
RELATIONSHIPS
Romantic Problems, Coworker Problems, Family 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?
Yes, via an app.
What areas of your life would you like to work on?
Stop daily drinking habit. Feel more comfortable and proud. Take better are of my body. Accomplish more things that make me happy.
What is the biggest challenge that you wish to work on during your session?
Shutting off daily drinking cravings/habit
Have you tried to do anything about this before now? If so, what?
I have read a lot about addiction, habits, and the subconscious.
EXPECTATIONS:
Help shut my craving subconscious program off.
Anything else I should know?
My childhood was good. If anything I think my drinking escalated from my relationship with my husband.
Are you willing to commit to listening to your personalized recording everyday for at least 21 days?
Absolutely!
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?