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Transformational Hypnosis Therapy
CLIENT NOTES:
Your content has been submitted
CLIENT INFORMATION
PREFERRED NAME:
DATE OF BIRTH:
PHONE NUMBER:
'+1 978-906-1618
ADDRESS:
EMERGENCY CONTACT NAME & NUMBER:
RELATIONSHIP STATUS:
OCCUPATION:
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.
Have you ever seen a counselor, psychotherapist, or psychologist for any issue? If yes, please explain.
Are you currently taking any prescribed medication? If yes, please list.
Have you experienced any traumatic life events that I should be aware of? If yes, please explain.
ADDICTIONS:
ANXIETY
EATING PROBLEMS
DEPRESSION
CAREER ISSUES
CONCEPTION PROBLEMS
PAIN CONTROL
RELATIONSHIPS
DIABETES
Have you ever had serious thoughts of harming yourself or others?
Do you or any member of your family have a history of epilepsy?
Have you ever been hypnotized before?
What areas of your life would you like to work on?
What is the biggest challenge that you wish to work on during your session?
Have you tried to do anything about this before now? If so, what?
EXPECTATIONS:
Anything else I should know?
Are you willing to commit to listening to your personalized recording everyday for at least 21 days?
Are you 18 years of age or older?
AGREE TO TERMS:
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?