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CLIENT NOTES:

Client Status

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CLIENT INFORMATION

PREFERRED NAME:

Sanya

DATE OF BIRTH:

November 9, 2024

PHONE NUMBER:

7816082161

ADDRESS:

1337 Ames Hill Dr, Tewksbury, MA 01876, USA

EMERGENCY CONTACT NAME & NUMBER:

Daniel Aminov

781-3636485

RELATIONSHIP STATUS:

Single

OCCUPATION:

Engineering

How did you hear about us?

Online

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, for family counseling

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, through life

ADDICTIONS:

None or N/A

ANXIETY

Fears, Panic Attacks, Trouble Relaxing

EATING PROBLEMS

None or N/A

DEPRESSION

Motivation

CAREER ISSUES

Driving Skills

CONCEPTION PROBLEMS

None or N/A

PAIN CONTROL

None or N/A

RELATIONSHIPS

Family Problems

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?

Fear of driving on a highway

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

Driving on a highway

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

No

EXPECTATIONS:

To overcome fear of driving

Anything else I should know?

No

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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