*First Name
*Last Name
*What do you like to be called?
*Gender
Male Female
*Date of Birth
Jan
Feb
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01
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*Marital Status
Please Choose
Single
Married
Divorced
Widowed
Spouse or Significant Other
Others in Household
(name & age)
*Occupation
*Phone
-
-
Ext
Please Select Type
Cell
Work
Home
Alternate Phone
-
-
Ext
Please Select Type
Cell
Work
Home
*Email
Address
(Number & Street)
City
*State
Not in the US
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
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IL
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OK
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PA
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*ZIP
Country
*How did you hear about Joe Oliver?
Please Choose
Friend
Business Associate
Work
Flyer
Google
Yahoo
Other Search Engine
Other web site
Other
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?
Please Choose
Daily
Constant
Weekly
Monthly
Every once in a while
Only when I ......
*Have you seen other professionals for any of
these issues/aspects?
Other MTT Professional
TFT Practitioner
MTT Practitioner
NLP Practitioner
Physician
Psychologist
Psychiatrist
Surgeon
Chiropractor
Massage Therapist
Acupuncture Practitioner
Reiki Practitioner
Other Alternative Health Practitioner
Other Professional
I have never seen a professional about this
(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?
Please Choose
Gotten Worse
Persisted or Stayed the same
Gotten Better
*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 Meridian Tapping Techniques
(MTT)?
*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.