John Koenig, Board Certified Hypnotist - Telephone Hypnosis Form

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. (Click the "Finish" button at the bottom of the form to complete).

 
1.

Please enter the information indicated below, including your preferred mailing address.


First Name:
Last Name:
Work Phone:
Home Phone:
Email Address:
emailaddress@xyz.com
Address 1:
City:
State/Province
(US/Canada):
Postal Code:

2.

Please provide the phone number you would like me to call for our phone sessions.

 

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3.

I can make a recording of your session which I will send you 2nd day USPS at no extra charge to the mailing address you provided above. I do not have the ability to make an MP3. Do you prefer:

CD
Audio cassette tape
I do not want a recording
Other  
4.

Your first choice for day/date, time and time zone for our first session. Allow approximately 60 minutes when you will be undisturbed. The broader time range you suggest, the easier it will be for me to accommodate you.

Example: Tuesday, July 5, 5-7 PM (Pacific Time Zone).

 

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5.

Your second choice for day/date, time and time zone for our first session. Allow approximately 60 minutes when you will be undisturbed. The broader time range you suggest, the easier it will be for me to accommodate you.

Example: Thursday, July 7, 3-4 PM (Pacific Time Zone).

 

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6.

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

 

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7.
Your gender?
Female
Male
8.
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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9.
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  
10.
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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11.
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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12.
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.   
13.
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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14.
What barriers or challenges do you face when dealing with this issue?
 

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15.
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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16.
What other issues would you like to address if possible?
 

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17.

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 magazine
Radio of TV Show
Other  
  • Comment:

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PLEASE READ BEFORE YOUR PHONE HYPNOSIS SESSION

You can experience your hypnosis by phone session through (in order of preference):

-Regular telephone
-A speaker phone
-Phone headset so that your hands are free

Avoid taking "recreational" drugs or alcohol before your session, as they can prevent you from becoming hypnotized or benefiting from the session. 

Make sure that you can relax and will be undisturbed for approximately  60 minutes. 

Disable call waiting or any electronic device that you think might disturb you. 

Also, be sure that other people won't enter the room during your hypnosis by phone session.  It is best to feel without any time pressure, so make sure you have no further appointments. 

Ask family or others sharing your home to be quiet and to avoid entering the room during your session.  It is important that you not be interrupted under any circumstances other than genuine and serious emergencies. You might even want to place a do not disturb sign on your door during the session.

Choose a place where you can be comfortable when you are being hypnotized.  Many people enjoy using a recliner during phone hypnosis however any other sort of comfortable furniture can work. You can even lie on the floor if that suits you.   Pets need to be in another room or space during your hypnosis by phone session.  This includes even your beloved cats or dogs.  Your temperature drops when you are in hypnosis so you may want to have a warm blanket. Make sure to take a bathroom break before your session begins.

Hypnosis and full bladders do not mix well.In the event that the connection should be lost, I will attempt to reconnect and continue immediately.  If we are not able to, we will reschedule your appointment via email. Naturally, we understand that circumstances might arise which would require you to change your appointment. 

In this case, please email me at jkhypnosis@aol.com as soon as you know and I will be happy to arrange another time for your session. Your CD or audiocassette of your phone hypnosis session will be mailed to you. Please make your payment 24 hours before your scheduled session or as soon as you send in the hypnosis by phone input form.            

 

PLEASE READ CAREFULLY BEFORE YOU HIT THE SUBMIT BUTTON.

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 Guild of Hypnotists, Ethics Committee, Merrimack, NH as well as any state agency.  

Note: John Koenig is a Board Certified Hypnotist (National Guild of Hypnotists). He holds a Bachelor of Psychology Degree from Hofstra University in Hempstead, New York and a Master of Arts Degree from the National University of Ireland in Dublin, Ireland. 

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

 
18.

 

The fee for your telephone hypnosis session is $95. Creation of a CD and shipment 2nd day USPS are free. Please indicate your preferred method of payment.

 

 

 
Credit Card (MasterCard, Visa, Discover) - You can give me this information over the phone at the start of our call.
I will mail you a check to: Possibilities Inc., PO Box 15151, Riverside, RI, 02915 (you must allow 2 weeks for check to clear prior to the session date}