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Transformational Hypnosis Therapy
CLIENT NOTES:
Your content has been submitted
CLIENT INFORMATION
PREFERRED NAME:
Pam
DATE OF BIRTH:
September 25, 1964
PHONE NUMBER:
781-760-1222
ADDRESS:
24 Captains Dr, Salem, NH 03079, USA
EMERGENCY CONTACT NAME & NUMBER:
Jack Marth
978-423-2910
RELATIONSHIP STATUS:
Husband
OCCUPATION:
Retired
How did you hear about us?
Internet
HEALTH INFORMATION
Are you being treated or have you ever been treated for any psychiatric illness? If yes, please explain briefly.
Depression and anxiety
Have you ever seen a counselor, psychotherapist, or psychologist for any issue? If yes, please explain.
Yes during my divorce
Are you currently taking any prescribed medication? If yes, please list.
Fluoxetine
FLOTICORTIZONE
Qulipta
Rizatriptan
Butal asa caff
Have you experienced any traumatic life events that I should be aware of? If yes, please explain.
Divorce at age 6
My own divorce when my kids were 6,7,9
Concussion in 2023
ADDICTIONS:
Drinking, Other
ANXIETY
Stress, Fears, Trouble Relaxing
EATING PROBLEMS
Weight Problems
DEPRESSION
Sleep Problems
CAREER ISSUES
CONCEPTION PROBLEMS
PAIN CONTROL
Inflammation, Sight/Vision
RELATIONSHIPS
Romantic Problems
DIABETES
Have you ever had serious thoughts of harming yourself or others?
Yes, when I was young
Do you or any member of your family have a history of epilepsy?
Younger sister
Have you ever been hypnotized before?
Yes- in my 20’s, with a group as a form of relaxation
What areas of your life would you like to work on?
Health and sleep
What is the biggest challenge that you wish to work on during your session?
Insomnia
Have you tried to do anything about this before now? If so, what?
Yes, yoga, exercise, CBD, melatonin, acupuncture, red light therapy.
EXPECTATIONS:
To be able to sleep better
Anything else I should know?
My health issues include:
Dysautonomia
Migraines and photophobia
Celiac and RA
I am having terrible mood swings
I can be impulsive
When I’m tired these all seem to get worse.
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?