CLIENT NOTES:
Your content has been submitted
CLIENT INFORMATION
PREFERRED NAME:
Mike
DATE OF BIRTH:
January 17, 1988
PHONE NUMBER:
978-551-8172
ADDRESS:
87 Hall St, Dunstable, MA 01827, USA
EMERGENCY CONTACT NAME & NUMBER:
Christine Baker
978-551-8172
RELATIONSHIP STATUS:
Wife
OCCUPATION:
Electrician
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.
I have been treated in the past for anxiety, add, meds were short lived
Have you ever seen a counselor, psychotherapist, or psychologist for any issue? If yes, please explain.
Yes but same thing very short lived
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.
ADDICTIONS:
None or N/A
ANXIETY
Stress, Guilt, Lack of Confidence
EATING PROBLEMS
None or N/A
DEPRESSION
Confidence, Sleep Problems
CAREER ISSUES
CONCEPTION PROBLEMS
PAIN CONTROL
RELATIONSHIPS
DIABETES
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?
I don’t think so, but saw a hypnotist once
What areas of your life would you like to work on?
I would like to somehow be less anxious / irritable, have patience, and just a better person.
What is the biggest challenge that you wish to work on during your session?
I am sick of being mad for no reason when I get home from work.
Have you tried to do anything about this before now? If so, what?
Seen my primary care, and got meds
EXPECTATIONS:
I just hope she can help me achieve my goals of being less angry.
Anything else I should know?
I noticed it says something about if your bi polar this treatment can make things worse, at one point my doctor put me on a medication to treat for bi polar but it didn’t work , but I was never officially diagnosed with bipolar disorder
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?
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?