Out-of-Work but In-Control (tm) - MOTIVATION GROUP - Application and Intake Form
Required Required Question(s)

This group is for people who are unemployed and looking for work who would like support in getting and staying motivated. It takes place every wednesday evening from 7:15PM to 8:30PM with the first meeting on September 9th, 2009.

To participate you must attend this September 9th meeting. In this meeting the program will be explained and you will be introduced to hypnosis. Anyone can experience hypnosis but it is important to learn how to get the most from the the program in this first session.

There is no cost for the Out-of-Work But In-Control Program, but, if you have a positive experience, you will be asked to share about it with friends and relatives who might benefit from hypnosis. There will be no pressue to do so, just a request.

Looking forward to meeting,
John Koenig, Certified Hypnotist
 
Required 1.

Please enter the information indicated below.
First Name:
Last Name:
Home Phone:
Email Address:
emailaddress@xyz.com
Address 1:
City:
State/Province
(US/Canada):
Postal Code:

2.

What is your age?
18 - 24
25 - 34
35 - 44
45 - 54
55 - 64
65 or older
3.
Your gender?
Female
Male
4.
Have you been hypnotized before?
No.
Yes in a Private Session - it was successful.
Yes in a Private Session - it was not successful.
Yes in a Group - it was successful.
Yes in a Group - it was not successful
Not sure.
  • Comment:

  • 500 characters left.
5.
Do you have any excessive fears or phobias?
No. Not really.
Open or closed spaces
Flying
Driving
Social situations
Insects, snakes, etc.
Water (beach, rivers, etc)
Other  
6.

Have you ever been hospitalized for a mental illness?

Yes
No
  • Comment:

  • 500 characters left.
7.

Where did you first hear of this program?
Radio show
Magazine or Newspaper Article
I am a former or current client of yours
Advertisement
Internet Search (google, yahoo, etc)
Brochure at Tree of Life Wellness or Gentle Chiropractic Center
Other  
  • Comment:

  • 500 characters left.
8.

How many of the Wednesday night meetings (7PM to 8:30PM) will you be able to attend? You must plan on attending at least four to enter the program.
At least four
At least five
All six
Sorry I can't attend four or more meetings at this time.
  • Comment:

  • 500 characters left.
Required 9.

How many months have you been out of work and looking for a new job?
 

  • 50 characters left.
10.

How would you rate the following?
 Very Negative Negative Okay Positive Very Positive 
My overall attitude
My confidence that I will find something acceptable soon
My confidence that I willf find something acceptable eventually
My motivation to do the legwork to look for work
My work search effort level over the past month
My confidence in my own ability to perform at work
My networking skills
My support network's strength (family, friends, aquaintances)
Required 11.

Please describe your current job search effort (what you do, how much time you spend, results so far, etc.)
 

  • 1000 characters left.

Participants will be selected for the program on a first come first admitted basis with a maximum of 20. You will receive an email within a few days letting you know if you are accepted.

 If the program is filled, your name will be kept on a waiting list and you will be informed if the program is offered again.

In the meantime, you may take advantage of a 50% discount on individual sessions ($42.50 per session rather than regular rate of $85).