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CLIENT NOTES:

Client Status

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CLIENT INFORMATION

PREFERRED NAME:

Lonny

DATE OF BIRTH:

October 9, 2024

PHONE NUMBER:

9786254300

ADDRESS:

460 East St, Tewksbury, MA 01876, USA

EMERGENCY CONTACT NAME & NUMBER:

Jeff

9789571054

RELATIONSHIP STATUS:

Friend

OCCUPATION:

Irrigation

How did you hear about us?

Boss

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.

No

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

No

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

No.

ADDICTIONS:

Smoking

ANXIETY

EATING PROBLEMS

None or N/A

DEPRESSION

None or N/A

CAREER ISSUES

None or N/A

CONCEPTION PROBLEMS

None or N/A

PAIN CONTROL

Chronic Pain

RELATIONSHIPS

None or N/A

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?

No

What areas of your life would you like to work on?

Smoking

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

Smoking

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

Yes

EXPECTATIONS:

Help nothing works for me. Patch sync gum

Anything else I should know?

Back pain making it hard to quit

Are you willing to commit to listening to your personalized recording everyday for at least 21 days? 

Sure.

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?

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