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CLIENT NOTES:

Client Status

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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

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