Name
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First Name
Last Name
Email
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Phone
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Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Date of Birth
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MM
DD
YYYY
Marital Status
Number of Children and their ages
Employment/Profession
Other Main Activities (Hobbies/Interests)
Have you ever heard of or used flower essences before? If yes, please explain...
What is your main reason for wanting to use flower essences now?
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You can select more than one.
If you selected 'Other' or 'Immediate Crisis' please describe here
1. How would you rate your overall physical health at the moment?
2. Do you have any current physical ailments or chronic conditions?
3. What does your typical daily diet look like?
4. Are there any specific foods or dietary restrictions you follow?
5. How often do you engage in physical exercise or activity?
6. What type of exercise do you usually do, and how do you feel about it?
7. Do you experience any physical symptoms related to stress or emotional states?
8. How would you describe your sleep patterns and quality?
9. Are there any recent changes in your physical health that concern you?
10. Do you use any supplements, medications, or alternative therapies?
1. How would you describe your current emotional state in a few words?
2. What emotions do you find yourself experiencing most frequently?
3. Are there specific situations or triggers that heighten your emotional responses?
4. How do you typically manage or cope with your emotions?
5. Do you experience any recurring emotional patterns or cycles?
6. What would you say is your greatest emotional challenge right now?
7. How do you feel about your relationships with others?
8. Do you have any past emotional traumas or unresolved feelings that affect you?
9. How do you feel about your current level of self-esteem and self-worth?
10. What emotional support systems or practices do you currently have in place?
1. How would you describe your current mental clarity and focus?
2. Do you often experience anxiety or racing thoughts?
3. Are there any specific mental or cognitive challenges you face?
4. How is your memory and concentration at present?
5. What mental health practices or therapies do you engage in, if any?
6. Do you experience any feelings of overwhelm or mental fatigue?
7. How would you describe your stress levels on a daily basis?
8. Are there any recurring thought patterns or beliefs that impact you negatively?
9. How do you handle mental stress and pressure?
10. Do you have any long-term or chronic mental health conditions?
1. How do you define your sense of purpose or meaning in life?
2. Can you describe any spiritual practices or rituals that are significant to you?
3. What role does spirituality play in your daily life and decision-making?
4. Do you follow any specific religious or philosophical beliefs? If so, which ones and how do they influence you?
5. What values or principles guide your actions and decisions?
6. How do you handle conflicts or challenges in a way that aligns with your spiritual or moral beliefs?
7. Do you have any spiritual mentors or role models? If so, who are they and why do they inspire you?
8. How do you find comfort or solace during difficult times?
9. What do you consider to be your greatest spiritual or moral strengths and areas for growth?
10. Are there any spiritual or ethical goals you are working towards or aspire to achieve?
How do you feel about your work and other vocational interests?
How do you feel about your relationship with others, especially major relationships?
Briefly discuss your family background...
What other therapies or significant growth experiences are you now undergoing?
If there’s anything else you believe is important for me to know or that could help in understanding your current state and needs, please feel free to share.
