Flower Essence Questionnaire Intake Form for Consultations

Thank you for purchasing a Flower Essence Consultation!

Consultation can be done via SKYPE call or in-person at our center.

NOTE: Before you schedule a SKYPE call with us, you must first fill out the Flower Essence Questionnaire Intake Form for your animal.

Flower Essence Questionnaire Intake Form:

Step 1 of 11

Your Order #*
Your order number can be found on the email receipt that was sent to you by [email protected] (not PayPal's invoice number).

It looks like this:
Name*
First Last
Email*
Download the Flower Essence Questionnaire or Use the Online Form*
You can either download the Flower Essence Questionnaire form in Word/PDF format and then upload your completed intake to this form, or you can utilize the online form. Please choose from the following:
- Download the Flower Essence Questionnaire
- Utilize the Online Form

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Download and Upload the Flower Essence Questionnaire Form*
You can download whatever format you would prefer to fill out the form:
Word Document
PDF
Once you have completed the form, please save the completed form to your computer for reference and upload it using the upload feature below.
Max. file size: 2 MB.

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Flower Essence Questionnaire
Use this questionnaire intake form and the flower essence category questions as a baseline as part of the individual in-depth consultation evaluation. Answer Yes or No to any of the following questions contained in each category. Use the “NEXT” tab to fill out each page. When completed, click the ‘SAVE & SUBMIT’ tab to send your form. The form is sent directly to the instructor for viewing of the individual form case study. Use a new form for each separate case study.
Date of Initial Consultation:
MM slash DD slash YYYY
Date of Follow up:
MM slash DD slash YYYY
Client's Name:
Species
Breed:
Sex:
Age:
Caregiver's Name:
First Last
Email*
Phone Number:
Reason/s for Flower Essence Use:
Has the client used flower essences prior, if so, list which and why, and include if there were good results or not:
Known Allergies:
Health Issues:
Overall Emotional Health (Personality, Characteristics, Past Issues (trauma/abuse/injuries, etc.)
Current emotional state:
Chronic emotional state:
Activities or issues that lead to or may have contributed to the emotional state:

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You're ready to submit your form.
You will receive email confirmation with the form fields you submitted.

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Step 1 of 11

Flower Essence Questionnaire

Category 1: Fear

Aspen

Cherry Plum

Mimulus

Red Chestnut

Rock Rose

Category 1: Bach Flower Essences Summary

Category 2: Uncertainty

Cerato

Gentian

Gorse

Hornbeam

Scleranthus

Wild Oat

Category 2: Bach Flower Essences Summary

Category 3: Lack of Interest in the Present

Chestnut Bud

Clematis

Honeysuckle

Mustard

Olive

White Chestnut

Wild Rose

Category 3: Bach Flower Essences Summary

Category 4: Loneliness

Heather

Impatiens

Water Violet

Category 4: Bach Flower Essences Summary

Category 5: Over-sensitive to Influences and Ideas

Agrimony

Centaury

Holly

Walnut

Category 5: Bach Flower Essences Summary

Category 6: Despondency and Despair

Crab Apple

Elm

Larch

Oak

Pine

Star of Bethlehem

Sweet Chestnut

Willow

Category 6: Bach Flower Essences Summary

Category 7: Over-care for the Welfare of Others

Beech

Chicory

Vervain

Vine

Rock Water

Category 7: Bach Flower Essences Summary

You're almost done!

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