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Transformational Hypnosis Therapy
CLIENT NOTES:
Your content has been submitted
CLIENT INFORMATION
PREFERRED NAME:
Maris
DATE OF BIRTH:
September 3, 1977
PHONE NUMBER:
9784067456
ADDRESS:
142 Carter St, Tewksbury, MA 01876, USA
EMERGENCY CONTACT NAME & NUMBER:
Jeff Bone
978-882-2239
RELATIONSHIP STATUS:
Married
OCCUPATION:
Companion Care
How did you hear about us?
Haha
HEALTH INFORMATION
Are you being treated or have you ever been treated for any psychiatric illness? If yes, please explain briefly.
PPD- with Quinn and Dezi
MDD- comes and goes. Not currently depressed
PTSD - this one is ongoing
Have you ever seen a counselor, psychotherapist, or psychologist for any issue? If yes, please explain.
I’m in therapy right now and have seen a therapist in the past at certain times
Are you currently taking any prescribed medication? If yes, please list.
Effexor XR- for depression
Valsartan- for high BP
Have you experienced any traumatic life events that I should be aware of? If yes, please explain.
3/2014 - Dezi’s fireplace accident
9/2014 - Assault by my stepfather
2014 - present Nightmare marriage
ADDICTIONS:
Smoking, Drugs
ANXIETY
Stress, Fears, Other
EATING PROBLEMS
Exercise
DEPRESSION
Motivation, Acheiving Goals, Procrastination, Self Sabotage, Sleep Problems
CAREER ISSUES
Concentration, Memory
CONCEPTION PROBLEMS
PAIN CONTROL
Skin Problems
RELATIONSHIPS
Childhood Problems, Romantic Problems, Family Problems
DIABETES
Have you ever had serious thoughts of harming yourself or others?
Here and there but not in years
Do you or any member of your family have a history of epilepsy?
My cousin had epilepsy and succumbed to the disease but she is the only one in my family, past or current
Have you ever been hypnotized before?
No
What areas of your life would you like to work on?
Let’s start with quitting vaping and quitting Kratom
What is the biggest challenge that you wish to work on during your session?
Those issues above
Have you tried to do anything about this before now? If so, what?
Yes I’ve tried willpower but have failed everytime. I did try the patch for vaping but I think my addiction is not just the nicotine but the ritual of smoking
EXPECTATIONS:
Heal me, sista!! Heal me!
Anything else I should know?
Maybe do a little reading up on Kratom to see the potential for abuse, withdrawal symptoms, etc.
Are you willing to commit to listening to your personalized recording everyday for at least 21 days?
Of course
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?