CLIENT NOTES:
Your content has been submitted
CLIENT INFORMATION
PREFERRED NAME:
Sara
DATE OF BIRTH:
January 14, 1980
PHONE NUMBER:
6035212653
ADDRESS:
14 Daniel Webster Dr, Hudson, NH 03051, USA
EMERGENCY CONTACT NAME & NUMBER:
Chad Belnap
603-305-5868
RELATIONSHIP STATUS:
Married
OCCUPATION:
Home maker
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.
N
Have you ever seen a counselor, psychotherapist, or psychologist for any issue? If yes, please explain.
Used one to quit smoking
Are you currently taking any prescribed medication? If yes, please list.
Diabetic meds
Have you experienced any traumatic life events that I should be aware of? If yes, please explain.
Lost father, abused as child
ADDICTIONS:
None or N/A
ANXIETY
Stress, Fears, Panic Attacks, Trouble Relaxing, Lack of Confidence, Other
EATING PROBLEMS
Food/Diet, Weight Problems, Exercise
DEPRESSION
Confidence, Self Esteem, Motivation, Procrastination, Self Sabotage, Sleep Problems
CAREER ISSUES
None or N/A
CONCEPTION PROBLEMS
None or N/A
PAIN CONTROL
Inflammation, Chronic Pain
RELATIONSHIPS
Childhood Problems, Family Problems
DIABETES
Type 1
Have you ever had serious thoughts of harming yourself or others?
Myself when really sick
Do you or any member of your family have a history of epilepsy?
No/not sure adopted
Have you ever been hypnotized before?
Yes, to quit smoking
What areas of your life would you like to work on?
Overcome GI issues, caused by stress, anxiety
What is the biggest challenge that you wish to work on during your session?
Stress, anxiety
Have you tried to do anything about this before now? If so, what?
Breathing app,
EXPECTATIONS:
Relieve stress anxiety while at home
Anything else I should know?
Brain fog,
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?