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CLIENT NOTES:

Client Status

Your content has been submitted

CLIENT INFORMATION

PREFERRED NAME:

Priya

DATE OF BIRTH:

June 8, 2005

PHONE NUMBER:

6179559045

ADDRESS:

EMERGENCY CONTACT NAME & NUMBER:

Rajesh Patel

7183546481

RELATIONSHIP STATUS:

Father

OCCUPATION:

Software Engineer

How did you hear about us?

Through my father

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.

no

Have you experienced any traumatic life events that I should be aware of? If yes, please explain.

no

ADDICTIONS:

None or N/A

ANXIETY

Stress, Guilt, Lack of Confidence

EATING PROBLEMS

None or N/A

DEPRESSION

Confidence, Self Esteem, Motivation, Acheiving Goals, Procrastination, Self Sabotage, Sleep Problems

CAREER ISSUES

Concentration, Exams

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?

yes

Do you or any member of your family have a history of epilepsy?

no

Have you ever been hypnotized before?

no

What areas of your life would you like to work on?

I would like to be able to study for my tests without feeling overwhelmed and get better grades

What is the biggest challenge that you wish to work on during your session?

Academic stressors

Have you tried to do anything about this before now? If so, what?

academic help sessions

EXPECTATIONS:

I am hoping that you can accommodate for any lack of experience in therapeutic sessions

Anything else I should know?

I do not have complete confidence in this process, but I am willing to try to reframe my mentality

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?

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