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CLIENT NOTES:

Client Status

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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?

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