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Transformational Hypnosis Therapy
CLIENT NOTES:
Your content has been submitted
CLIENT INFORMATION
PREFERRED NAME:
Ryan
DATE OF BIRTH:
February 3, 1997
PHONE NUMBER:
6319012195
ADDRESS:
140 Parlmont Park, North Billerica, MA 01862, USA
EMERGENCY CONTACT NAME & NUMBER:
KERRY CONLON
6313797812
RELATIONSHIP STATUS:
Mother
OCCUPATION:
Medical assistant
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.
Yes I’ve been in therapy since childhood and have been seeing psychiatry since 13 years old trying most SSRI’s. I’ve also tried outpatient facilities as well as TMS, ECT and ketamine injection therapy
Have you ever seen a counselor, psychotherapist, or psychologist for any issue? If yes, please explain.
Yes for mostly depression and handling anxiety
Are you currently taking any prescribed medication? If yes, please list.
Duloxetine 30mg once daily
Duloxetine 20mg once daily
Clonazepam 0.5mg three times daily as needed
Bupropion 200mg once daily
Bupropion 150mg once daily
Propranolol 10mg three times daily as needed
Quetiapine 50mg once nightly
Quetiapine 25mg once daily as needed
Have you experienced any traumatic life events that I should be aware of? If yes, please explain.
Yes my step father was physically abusive with my mother
ADDICTIONS:
Smoking, Compulsive Behavior
ANXIETY
Stress, Fears, Phobias, Panic Attacks, Compulsive Behavior, Guilt, Trouble Relaxing, Lack of Confidence
EATING PROBLEMS
Food/Diet, Exercise
DEPRESSION
Confidence, Self Esteem, Motivation, Acheiving Goals, Procrastination, Self Sabotage, Sleep Problems
CAREER ISSUES
Interview Skills, Public Speaking, Concentration, Memory, Driving Skills
CONCEPTION PROBLEMS
None or N/A
PAIN CONTROL
Inflammation
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?
Mostly mental, specifically handling or getting rid of physical manifestations of anxiety such as sweating and other behavioral changes that make it difficult to stay professional at work
What is the biggest challenge that you wish to work on during your session?
Over active sweating (presumably due to anxiety)
Have you tried to do anything about this before now? If so, what?
Yes I’m currently seeing endocrinology, neurology, dermatology and my primary to find the root cause of these issues but nothing has come to light
EXPECTATIONS:
I’m hoping to truly get hypnotized and also use that to help myself move forward with some of my issues I feel are too deep rooted for me to handle as is.
Anything else I should know?
I don’t think so
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?