Past Life Exploration Information Form
Past life regression hypnosis is not psychotherapy: rather it is a spiritual exploration that may or may not have impact on whatever issues/challenges you face in your current lifetime. While the intention is beneficial and outcomes are usually enlightening, you must be willing to experience potentially upsetting moments during your past life journey such as death, violence or betrayal in a past incarnation. For that reason, if you are in therapy, it is important that you get your therapist's approval before we can do this work. By agreeing to participate you declare that you are responsible for your own physical and emotional well being.
 

 

Please take a moment to answer a few questions. Your information will be kept confidential. Make sure to click the FINISH button once you complete the form.  

 

 Please fill out the form and then call me at 401-374-1890 to schedule your appointment (roughly 115 minutes). 

 
1.
Please enter the information indicated below.

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

2.
Are you ready to start?
Yes. I am ready to schedule a personal session.
Thinking about it and would like to talk
I am signed up for a workshop you are offering
Other  
  • Comment:

  • 500 characters left.
3.

Please briefly describe your thoughts about and experience with past lives and reincarnation. 

 

350 characters left.
4.
If you will be attending a public workshop only: do you agree to respect the confidentiality of workshop members and agree to honor their right to experience whatever they experience during the workshop?
Yes
No
Not applicable
5.

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

 

50 characters left.
6.
Your gender identification in your current incarnation?
Female
Male
Trans
Non-binary
Fluid
7.
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.
8.

Have you done any past life work before and (if so) with whom? 

Yes
No
Other  
  • Comment:

  • 500 characters left.
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.
Are you in therapy - and - if so - have you informed your therapist and gotten their agreement it is okay for you to go forward?
Not in therapy - never was.
Not in therapy - was in the past.
Currently in therapy (please list therapist's name below) and my therapist knows I am looking at this and does not have an objection
I am in therapy (please list therapist's name below) and I have not yet told him or her about my interest in exploring my past lives
  • Comment:

  • 500 characters left.
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:

  • 500 characters left.
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 achieve with past life hypnosis work?
General spiritual growth
Satisfy curosity
Get clarity about an issue I am facing
Break through a barrier I am facing
Other  
  • Comment:

  • 500 characters left.
14.
Anything else you think I should know about you before we start?
 

350 characters left.
15.

 

 What made you consider me as your past life guide?




 


 
Internet Search
Article or interview
Referred by a friend
Advertisement in RI Wellness Guide
Existing client who wants to try a past life exploration
Advertisement in Natural Awakenings Magazine
Other  
  • Comment:

  • 500 characters left.

 

CLIENT "BILL OF RIGHTS" 

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 and is certified and trained to instruct new professional hypnotists (National Guild of Hypnotists).


John is not a medical doctor or licensed psychologist, psychotherapist, social worker, dietition or nutritionist and does not diagnose or treat any illness. He holds a Bachelor of Arts Degree in Psychology (Hofstra University, Hempstead, NY) and a Master of Arts Degree earned at the National University of Ireland (Dublin, Republic of Ireland).