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Transformational Hypnosis Therapy
CLIENT NOTES:
Your content has been submitted
CLIENT INFORMATION
PREFERRED NAME:
quinn
DATE OF BIRTH:
July 18, 2005
PHONE NUMBER:
978-788-4662
ADDRESS:
142 Carter St, Tewksbury, MA 01876, USA
EMERGENCY CONTACT NAME & NUMBER:
Marisa
978-406-7456
RELATIONSHIP STATUS:
mother
OCCUPATION:
lift operator for vail resorts
How did you hear about us?
mother
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.
i’ve only seen therapists for my mom and step dad getting into fights. and when I watched a buddy of mine die in my arms after a motorcycle accident
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.
yes, I was out on a motorcycle ride with my buddy, and he ended up going really fast, passed me, and hit the tree and was bleeding everywhere out of his head, eyes, ears, and I went over to him, and he died in my arms.
ADDICTIONS:
None or N/A
ANXIETY
Stress, Panic Attacks, Guilt, Trouble Relaxing, Lack of Confidence
EATING PROBLEMS
None or N/A
DEPRESSION
Confidence, Self Esteem
CAREER ISSUES
Memory
CONCEPTION PROBLEMS
None or N/A
PAIN CONTROL
RELATIONSHIPS
None or N/A
DIABETES
None or N/A
Have you ever had serious thoughts of harming yourself or others?
no
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 work on mental, Emotional and confidence.
What is the biggest challenge that you wish to work on during your session?
getting my mind straight from The past traumatic Experience, I would like to get the visions out of my head throughout the day. I would like to get the triggers away that bring back the memories of the motorcycle accident. when I start to think of my buddy, I would like to vision him, smiling and happy and not bleeding out of his head.
Have you tried to do anything about this before now? If so, what?
yes, I have gone to a breath, work class. talked to a pastor that had a pretty similar experience that I could relate to which made me feel a little better. and I would go on motorcycle rides every day and it made me feel better
EXPECTATIONS:
hoping by the end of this, I can start living my life a little better and when life starts to get a little slow or nothing is happening I won’t get those traumatic thoughts.
Anything else I should know?
That I’ll probably start getting really emotional and not wanting to talk about it. But I am going to need to get pushed through it.
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?