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Transformational Hypnosis Therapy
CLIENT NOTES:
Your content has been submitted
CLIENT INFORMATION
PREFERRED NAME:
Nicole
DATE OF BIRTH:
September 3, 1978
PHONE NUMBER:
9786095900
ADDRESS:
105 Litchfield Ave, Dracut, MA 01826, USA
EMERGENCY CONTACT NAME & NUMBER:
Sean Doyle
9787717344
RELATIONSHIP STATUS:
Married
OCCUPATION:
Patient Service Rep
How did you hear about us?
Searching google
HEALTH INFORMATION
Are you being treated or have you ever been treated for any psychiatric illness? If yes, please explain briefly.
I have medications to start but am petrified to take them.
Have you ever seen a counselor, psychotherapist, or psychologist for any issue? If yes, please explain.
Currently seeing therapist for talk therapy and therapist for chronic pain management therapy to help retrain my brain. Was working with energy/holistical worker but have not for a few weeks due to her personal issues. Also, working with a nutritionist.
Are you currently taking any prescribed medication? If yes, please list.
No, but am prescribed fluoxetine (Prozac) 10mg for one week then increase to 20mg. Alprazolam (Xanax) 0.25mg twice a day as needed
Have you experienced any traumatic life events that I should be aware of? If yes, please explain.
Dad had 3 episodes of anaphylactic years ago, he lived but they never found the allergy, that has always stuck with me. Nephew (21 years old) and two cousins overdosing. I do believe these things play a huge role with my health anxiety, taking any medications and eating. My mind always goes to the negative and fearful.
ADDICTIONS:
None or N/A
ANXIETY
Stress, Fears, Phobias, Panic Attacks, Trouble Relaxing, Lack of Confidence
EATING PROBLEMS
Food/Diet
DEPRESSION
Confidence, Self Esteem, Motivation, Acheiving Goals, Procrastination, Sleep Problems
CAREER ISSUES
Interview Skills, Public Speaking, Concentration
CONCEPTION PROBLEMS
None or N/A
PAIN CONTROL
Mobility, Inflammation, Skin Problems, Chronic Pain
RELATIONSHIPS
Family Problems
DIABETES
None or N/A
Have you ever had serious thoughts of harming yourself or others?
Never
Do you or any member of your family have a history of epilepsy?
Not that I know of
Have you ever been hypnotized before?
Energy worker has tried to get me in a relaxed state, maybe hypnotic, but I’m thinking your techniques are much different.
What areas of your life would you like to work on?
I want to focus on me and overcome being so fearful and constant anxiety. I want to eat like a normal person and go on dinner dates with my husband and be able to plan a vacation and not worry.
What is the biggest challenge that you wish to work on during your session?
Anxiety, panic and being able to eat.
Have you tried to do anything about this before now? If so, what?
Lots of visits to the ER, begged to go inpatient and was not a candidate. Talked to many therapists to try to find a connection. I feel I have a good team now and trying to also work on self care.
EXPECTATIONS:
Feel better!
Anything else I should know?
I’m really struggling with everyday life because of all this anxiety and panic.
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?