John Koenig, Board Certified Hypnotist - New Client General Intake Form
Required Required Question(s)

Please take a moment to answer a few questions. Your response to these will help me tailor a hypnosis program to meet your needs and expectations. Your information will be kept confidential. (Click the "Finish" button at the bottom of the form to complete)
 
1.

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

2.

NOTE: You will need to call to schedule your actual appointment.

Call 401-374-1890 for an appointment in Warwick, RI 
(110 Jefferson Blvd, Suite B))

   Tues:     9am -  8pm
   Wed:      9am - 12pm
   Thurs:    9am - 8pm
   Fri:         9am - 12pm
   Sat:        9am - 11am

Call 508-336-4242 for an appointment in Seekonk, MA 
(Tree of Life Wellness Center, 1460Fall River Ave)

   Wed:    3pm - 6pm
   Fri:     12:30pm - 6pm
   Sat:    12pm - 5PM
 
I am unable to schedule appointments online. You must make the scheduling call yourself.

Please also enter your phone number below in case I have to reach you in the rare event that I need to cancel an appointment.
 

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3.
I make a free recording of your actual hypnosis session. Most find this very helpful for reinforcement. Please indicate wether you would like one and, if so, what format.
Yes - a CD
Yes - An audio cassette tape
No thank you
Required 4.

What is your date of birth (month, day and year)?
 

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5.
Your gender?
Female
Male
6.
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:

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7.
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  
8.
Experience with psychotherapy.
Not in therapy - never was.
Not in therapy - was in the past.
Currently in therapy (please list therapist's name below).
  • Comment:

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9.
What are your attitudes and expectations about hypnosis? We will talk about hypnosis and what to expect at your session and I will answer any questions. But your answers to these questions will give me an idea of your current understanding and expectations.
 Strongly Agree Agree Not Sure Disagree Strongly Disagree 
Hypnosis is like going to sleep
Hypnosis works on the power of suggestion.
People can be made to do things against their will through hypnosis
I should not expect to remember anything that happens during hypnosis
Hypnosis can relieve pain. Surgery can even be performed with hypnosis
Strong willed people make poor hypnosis subjects
A single session will cure most problems
Some people cannot be hypnotized even if they want to be
A hypnotist must use something like a metronome, watch shinny object
All hypnosis is really self-hypnosis
  • Comment:

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10.
Everyone can be hypnotized. However, people respond to hypnosis in different ways. This little survey will help me understand how to best help you achieve a productive hypnotic state. Thank you for your patience.
 Never have this experience. I occasionally have this experience. I often have this experience.   
Sometimes I feel and experience things like I did as a child.   
I can be greatly moved by an eloquent speech or poetry.   
I may become so involved watching tv/movies that I "lose" myself in it   
I have driven past my exit while absorbed in thoughts or daydreams.   
Sometimes I daydream or imagine so vividly I "lose" myself in it.   
I think I know what people mean who talk about mystical experiences.   
A voice's sound can be so fascinating I want to keep listening.   
Different colors have distinctive and special meanings for me.   
My mind may wander off during routine tasks and I forget about time   
Vivid memories are often brought up by scents and smells.   
11.
What is the main issue you wish to handle with hypnosis? While we can often add a secondary objective, it is best to have a clear focus for your session.
Smoking Cessation
Weight Loss
Stress Reduction
Confidence Building
Memory or Concentration
A.D.D. HypnoCoaching
Career HypnoCoaching
Sales Person HypnoCoaching
Flying, Driving, Public Speaking Fears
Problems with Alcohol (moderate or stop drinking, 12-step program support)
Problems with Recreational Drugs Other than Alcohol (marijuana to opiates)
Educational Issues (test taking anxiety, study skills)
Difficult Relationships (toxic relationships, marital, obsessions, divorce)
Psychotherapy Complement (boosting your results in therapy)
Pre-Surgery Hypnosis (fear reduction, healing support)
IBS
Skin Problems (warts, rashes, blushing)
Pain Management
Complusive Hair Pulling, Skin Scratching
Social Anxiety
Other  
  • Comment:

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12.
What barriers or challenges do you face when dealing with this issue?
 

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13.
What have you done so far to deal with this issue? Please list professionals you have seen, programs you have tried, describe your personal efforts, etc.
 

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14.
What other issues would you like to address if possible?
 

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15.

Where did you first hear of me (please list friend, doctor or therapist's name at bottom if you were referred)?
Referred by a doctor or therapist
Craigslist
Referred by a friend
Advertisement on Facebook
Advertisement on Google
Internet Search (google, yahoo, etc)
Merchant Circle Listing
Advertisement in Natural Awakenings Magazine
Sign or brochure at Gentle Chiropractic Center
Brochure at Tree of Life Wellness Center
Radio Show - WHJJ
Radio Advertisement
Other  
  • Comment:

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16.
MEDICAL ISSUES ONLY: It is important that your physician be given the chance to add his or her input if you would like to address certain issues with hypnosis. These include but are not limited to: eating disorders (bulima, aneroxia), IBS, Fibromyalgia, pain management. Please provide your physician's name and address if you give your permission for me to contact them.
 

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Please read carefully before you complete this intake form. All conversations and transactions between hypnotist and client are confidential and will not be disclosed except by the client's written authorization.

The length, content and approach of each session are to be agreed upon prior to the hypnotic consultation. It is the client's right to know the estimated number of sessions recommended to achieve his or her goals. It is the client's right to file a complaint with the National Board of Hypnotists, Ethics Committee, Merrimack, NH as well as any state agency. It is the client's right to refuse any process by his or her own determination and to end hypnotherapy whenever he or she wishes with a pro-rated refund. It is the client's right to have the name of other practitioners in the community who may be available to work with him or her. Note: John Koenig is a Board Certified Hypnotist (National Guild of Hypnotists).

 He is not a medical doctor or licensed psychologist, psychotherapist, social worker, nutritionist or dietitation and does not diagnose or treat any illness.