PERSONAL DETAILS

HEALTH

Are you being treated or have you ever been treated for any psychiatric illness? If yes, please explain briefly.*

Have you ever seen a counselor, psychotherapist, or psychologist for any issue? If yes, please explain.*

Are you currently taking any prescribed medication? If yes, please list.*

Have you experienced any traumatic life events that I should be aware of? If yes, please explain.*

ADDICTIONS:

ANXIETY:

EATING PROBLEMS:

DEPRESSION:

CAREER ISSUES:

CONCEPTION PROBLEMS:

PAIN CONTROL:

RELATIONSHIPS:

DIABETES:

Have you ever had serious thoughts of harming yourself or others?*

Do you or any member of your family have a history of epilepsy?*

Have you ever been hypnotized before?*

What areas of your life would you like to work on, i.e. overcome health issues /physical /mental /emotional/ spiritual issues/setting and accomplishing goals/life purpose or something else.*

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

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

Expectations for working with Stephanie

Is there anything else you feel Stephanie should know prior to working together?

Are you willing to commit to listening to your personalized recording everyday for at least 21 days?*

Are you 18 years of age or older?

Clients under the age of 18 MUST have a consent form signed.

WEIGHT CLIENTS ONLY

If you are booking a session for weight, body or food issues, please fill out this section.

What is your current weight?

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 don’t weigh yourself, what is the largest and smallest size you have 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? If so, what is the difference between the two? Are good days hard for you? What would you do on your worst day?

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: Write down what you ate in the last 24hrs. Include the time of day and details about what you ate.

Is this a typical day for you? If not, what is a more typical day like?