FEARLESS FLYING INTAKE FORM
     Barrington Public Library  
        (Monday, April 13th   
             6:30-8:30 PM)
 
    -Group Discussion
    -Two Group Hypnosis Sessions  
    -Only $50
FREE CD for Reinforcement
 

 

Please take a moment to answer a few questions. Keep in mind this program is not psychotherapy, but is for people with mild to moderate fear associated with flying. Your information will be kept confidential. Make sure to click the FINISH button and complete your $50 payment once you finish the form.  

 

Feel free to call me anytime at 401-374-1890. 

 
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.

Please briefly describe your problem with flying (when it started - what happens when you fly/think about flying and indicate if, whether and when you have an upcoming flight scheduled). 

 

1000 characters left.
3.
I make a free recording to reinforce the class. Most find this very helpful for reinforcement. Please indicate whether you would like one. There is no extra cost.
Yes
No thanks
4.

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

 

50 characters left.
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:

  • 500 characters left.
7.
Do you have any other excessive fears or phobias?
No. Not really.
Open or closed spaces
Driving
Social situations
Insects, snakes, etc.
Water (beach, rivers, etc)
Other  
  • Comment:

  • 500 characters left.
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:

  • 500 characters left.
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:

  • 500 characters left.
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 have you done so far to deal with your flying problemt? Please list professionals you have seen, programs you have tried, describe your personal efforts even if all they include is a trip to the airport bar pre-flight.
 

50 characters left.
12.

 

 

Where did you first hear of this class (please list friend, doctor or therapist's name at bottom if you were referred)?




 


 
Referred by a doctor or therapist
Referred by a friend
Advertisement on Google
Internet Search (google, yahoo, etc)
Barrington Times Article
E-MAILING - I am a current or past client
Facebook
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).