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Transformational Hypnosis Therapy
CLIENT NOTES:
Your content has been submitted
CLIENT INFORMATION
PREFERRED NAME:
Mel
DATE OF BIRTH:
October 5, 1962
PHONE NUMBER:
5083283895
ADDRESS:
9 Mill St apt 3, Maynard, MA 01754, USA
EMERGENCY CONTACT NAME & NUMBER:
Nick Constantine
(774) 270-3001
RELATIONSHIP STATUS:
Son
OCCUPATION:
Administrative Assistant
How did you hear about us?
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.
Bupropion and Simvastatin
Have you experienced any traumatic life events that I should be aware of? If yes, please explain.
Divorce. AD estrangement
ADDICTIONS:
Other
ANXIETY
Stress
EATING PROBLEMS
Food/Diet, Exercise
DEPRESSION
Sleep Problems
CAREER ISSUES
None or N/A
CONCEPTION PROBLEMS
None or N/A
PAIN CONTROL
None or N/A
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?
Yes
What areas of your life would you like to work on?
Emotional eating with sugar addiction
What is the biggest challenge that you wish to work on during your session?
Sugar and elimination of it
Have you tried to do anything about this before now? If so, what?
No
EXPECTATIONS:
Hope and faith Stephanie can help me
Anything else I should know?
No
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?
180
When was the last time you were at or near this weight?
2018
What is the heaviest and lightest you have ever been?
119 lbs. 232 lbs
If you could design a relationship with food, what would it be like?
Only healthy food stuff
Can you leave food or throw it away?
Yes sometimes
Do you eat when you are bored, stressed or tired, or experiencing another emotion?
Yes
Do you use food to comfort yourself?
Yes
Do you have good and bad days?
No. Just says when I didn’t get much sleep so I have extra coffee
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?
Maybe? I used to hoard cookies
Were any foods forbidden to you growing up?
None that I recall
Do you prefer to cook or eat out?
Eat in but I’m not a good cook
24-Hour Recall
Is this a typical day for you?