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Transformational Hypnosis Therapy
CLIENT NOTES:
Your content has been submitted
CLIENT INFORMATION
PREFERRED NAME:
Raji
DATE OF BIRTH:
June 12, 1970
PHONE NUMBER:
9788464981
ADDRESS:
5 Maple Road, Westford, MA, USA
EMERGENCY CONTACT NAME & NUMBER:
Karthik Ravichandran
9788460852
RELATIONSHIP STATUS:
Married
OCCUPATION:
Special Education Teacher
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.
no
Have you ever seen a counselor, psychotherapist, or psychologist for any issue? If yes, please explain.
Yes- Depression, Anxiety
Are you currently taking any prescribed medication? If yes, please list.
Escitalopram, Bupropion
Have you experienced any traumatic life events that I should be aware of? If yes, please explain.
Yes, several
Health, Marriage, Death of Mom, My children, Husband's cancer diagnosis
ADDICTIONS:
None or N/A
ANXIETY
Stress, Fears, Panic Attacks, Guilt, Trouble Relaxing, Lack of Confidence
EATING PROBLEMS
Food/Diet, Exercise
DEPRESSION
Confidence, Self Esteem, Motivation, Acheiving Goals, Self Sabotage, Sleep Problems
CAREER ISSUES
Concentration
CONCEPTION PROBLEMS
PAIN CONTROL
Hair Growth
RELATIONSHIPS
Childhood Problems, Peer Problems, Coworker Problems, Family Problems
DIABETES
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?
Yes- Self--- But completely cured after brain surgery in 2002
Have you ever been hypnotized before?
no
What areas of your life would you like to work on?
mental, emotional, life purpose, self confidence, self love, spiritual connection, letting go of past, eradicate self-doubt
What is the biggest challenge that you wish to work on during your session?
spiritual growth, self confidence, self love, hair growth
Have you tried to do anything about this before now? If so, what?
Yes, counseling, medication, CBT
EXPECTATIONS:
Need to see a change
Anything else I should know?
none
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?