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Transformational Hypnosis Therapy
CLIENT NOTES:
Your content has been submitted
CLIENT INFORMATION
PREFERRED NAME:
Mark
DATE OF BIRTH:
September 19, 1992
PHONE NUMBER:
7816263324
ADDRESS:
9 Bradner St, Foxborough, MA 02035, USA
EMERGENCY CONTACT NAME & NUMBER:
Brenda Pipher
5087405435
RELATIONSHIP STATUS:
Mother
OCCUPATION:
Software Engineer
How did you hear about us?
Google search
HEALTH INFORMATION
Are you being treated or have you ever been treated for any psychiatric illness? If yes, please explain briefly.
Yes, Anxiety and depression.
Have you ever seen a counselor, psychotherapist, or psychologist for any issue? If yes, please explain.
Yes, Anxiety, OCD, Depression.
Are you currently taking any prescribed medication? If yes, please list.
Yes, Lorazepam 1mg as needed, venlafaxine 150mg.
Have you experienced any traumatic life events that I should be aware of? If yes, please explain.
Yes, when I was 19, I started noticing a sensation in my throat that turned out to be possibly acid reflux after many tests. Ever since then I have had issues come up for the years and a lot of health anxiety, eye floaters came on instantly, had an issue working out and caused chronic pelvic pain syndrome that had mostly subsided to this day.
Different noteL I was bullied throughout most of elementary school because I had a lot of seperation anxiety starting in the 2nd grade from my mom leaving me at school. I would try to run away crying while the teachers had to get me to stay.
ADDICTIONS:
Drinking, Smoking
ANXIETY
Stress, Fears, Guilt, Trouble Relaxing, Lack of Confidence
EATING PROBLEMS
None or N/A
DEPRESSION
Self Sabotage
CAREER ISSUES
None or N/A
CONCEPTION PROBLEMS
None or N/A
PAIN CONTROL
Inflammation, Chronic Pain
RELATIONSHIPS
Childhood Problems, Romantic 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?
No.
What areas of your life would you like to work on?
overcoming health issues, fear of losing control, fear of being alone, finding a purpose even though I feel like I already should have one.
What is the biggest challenge that you wish to work on during your session?
Anxiety, past stress, traumas. Possibly smoking cession.
Have you tried to do anything about this before now? If so, what?
I've tried behavioral therapy and medidation but it did not help enough.
EXPECTATIONS:
I do not have any, I am going into this very open-minded.
Anything else I should know?
I have struggled with addiction issues most of my life. I've gone through periods in my life where I find that it is near impossible to be completely sober, however I am 4 months sober now. I still think a lot about drinking, especially since giving up smoking cigarettes a few days ago. I have not had any issues with anything other than nicotine addiction, marijuana smoking infrequently, and drinking heavy in the past.
Are you willing to commit to listening to your personalized recording everyday for at least 21 days?
Yes I am.
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?