CLIENT NOTES:
Your content has been submitted
CLIENT INFORMATION
PREFERRED NAME:
Laurie
DATE OF BIRTH:
March 8, 1961
PHONE NUMBER:
2073222674
ADDRESS:
EMERGENCY CONTACT NAME & NUMBER:
Toney hall
2072238010
RELATIONSHIP STATUS:
Husband
OCCUPATION:
Self employed
How did you hear about us?
Internet
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, 1987 i had a nervous breakdown
Are you currently taking any prescribed medication? If yes, please list.
Yes
Have you experienced any traumatic life events that I should be aware of? If yes, please explain.
No
ADDICTIONS:
None or N/A
ANXIETY
Guilt, Lack of Confidence
EATING PROBLEMS
Food/Diet, Weight Problems, Exercise
DEPRESSION
Confidence, Self Esteem, Motivation, Acheiving Goals, Self Sabotage
CAREER ISSUES
None or N/A
CONCEPTION PROBLEMS
None or N/A
PAIN CONTROL
Inflammation
RELATIONSHIPS
None or N/A
DIABETES
None or N/A
Have you ever had serious thoughts of harming yourself or others?
1987 when I had my nervous break down I wanted to kill 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?
Weight
What is the biggest challenge that you wish to work on during your session?
Letting go of guilt when I lost 100 pounds 5 years ago but put it back on
Have you tried to do anything about this before now? If so, what?
No
EXPECTATIONS:
To help me achieve this in my life and keep it off
Anything else I should know?
I own my own business a 6 bed facility and also am a Pastor
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?
170
When was the last time you were at or near this weight?
5 years ago
What is the heaviest and lightest you have ever been?
Largest is 290 and smallest since adult is 150
If you could design a relationship with food, what would it be like?
That i would not keep stuffing my emotions with food for comfort. Right now my husband has brain cancer. That's a struggle the past 6 months
Can you leave food or throw it away?
I have
Do you eat when you are bored, stressed or tired, or experiencing another emotion?
All the above
Do you use food to comfort yourself?
Yes
Do you have good and bad days?
Good days are not as hard. Worst day is eating what's ever in sight
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
Were any foods forbidden to you growing up?
No
Do you prefer to cook or eat out?
Eat out when I can
24-Hour Recall
2 bowls Corn chowder, donuts 2, chips, cookies, 2 chicken sandwiches,
Is this a typical day for you?
I don't usually have chowder, usually a sandwich at lunch, main meal at supper and evening just eating chips, cookies anything comfort