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Transformational Hypnosis Therapy
CLIENT NOTES:
Your content has been submitted
CLIENT INFORMATION
PREFERRED NAME:
Walt
DATE OF BIRTH:
August 10, 1968
PHONE NUMBER:
1 617 791 0941
ADDRESS:
9 Moran Rd, North Billerica, MA 01862, USA
EMERGENCY CONTACT NAME & NUMBER:
Rasa Rich
1 617 930 5680
RELATIONSHIP STATUS:
wife
OCCUPATION:
letter carrier USPS
How did you hear about us?
internet
HEALTH INFORMATION
Are you being treated or have you ever been treated for any psychiatric illness? If yes, please explain briefly.
anxiety
Have you ever seen a counselor, psychotherapist, or psychologist for any issue? If yes, please explain.
cbt therapy
Are you currently taking any prescribed medication? If yes, please list.
Mirtazapine, Buspar, and Klonopin
Have you experienced any traumatic life events that I should be aware of? If yes, please explain.
no
ADDICTIONS:
ANXIETY
Stress, Fears, Phobias, Panic Attacks, Compulsive Behavior, Guilt, Trouble Relaxing
EATING PROBLEMS
DEPRESSION
Confidence, Sleep Problems
CAREER ISSUES
Public Speaking, Memory
CONCEPTION PROBLEMS
PAIN CONTROL
RELATIONSHIPS
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?
no
Have you ever been hypnotized before?
no
What areas of your life would you like to work on?
I would like to relieve my anxiety. Overcome my fear of elevators, and planes. Claustrophobia in general.
What is the biggest challenge that you wish to work on during your session?
my anxiety
Have you tried to do anything about this before now? If so, what?
no
EXPECTATIONS:
That she can help relieve my anxiety.
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?