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Joe Oliver, EFT Practitioner
 

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This confidential online form takes approximately 10 minutes to complete. You can not save your information and return later as this information is not stored, it is sent directly to Joe Oliver.  Items marked with an " * " are required.

 
*First Name  
*Last Name  
*What do you like to be called?  
*Gender  Male        Female
*Date of Birth                             
*Marital Status  
Spouse or Significant Other
Others in Household
(name & age)
*Occupation  
*Phone

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Alternate Phone - -     Ext    
*Email  
Address (Number & Street)
City
*State  
*ZIP  
Country
*How did you hear about Joe Oliver?  
If Other, please explain:
Major complaint(s), symptoms, issues/aspects
(in order of priority if more than one)		 *1.
2.
3.
4.
5.
*When did the above issues/aspects begin?  
*How often does your #1 issue/aspect bother you?  
*Have you seen other professionals for any of these issues/aspects?
 		  
(choose more than one by holding the
CTRL key while making your selections)
What types of treatments have you had?
What type of results have you experienced?
Can you relate any of the issues/aspects you listed above to any events in your life? What events?
*Since it first began, what best describes your #1 issue/aspect listed above?  
*What makes your #1 issue/aspect worse?  
*What makes your #1 issue/aspect better?  
*List any illnesses, diseases, accidents, stress-related events as an adult or in childhood) that may be related to any of your issues/aspects:  
Please rate your current stress level about your #1 issue/aspect on this scale: 1 2 3 4 5 6 7 8 9 10

1=Very Little                                      10=Very High
*Are you currently taking any medications?  Yes  No
Do you have any medical conditions that I need to be aware of?
*Do you or does anyone in your family have a history of substance abuse?  Yes, Me   Yes, Family  No
*What is your experience with EFT?  
*Please describe your current issues/aspects that bring you to a session (i.e. symptoms) in as much detail as you believe will be helpful  
Please list three specific events that you feel may have contributed to your problem

 		 *1. The time when....
 
2. The time when...

3. The time when...
If you were to live life over, what person or event would you prefer to skip?

 
What makes you angry and why?
What was the last time you cried and why?
What is your biggest regret or sadness?
What is missing in your life to make it ideal?
Who would be upset if you were completely "healed"?
What do you wish you had never done?
What is one positive goal you would like to achieve?
How would your life be different if/when we handle all of your issues?

 This information is strictly confidential, and will be submitted directly to Joe Oliver.

      

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