CLIENT NOTES:
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?