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You are here: Home / Flower Essence Questionnaire Intake Form for Consultations

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

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  • 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:
  • 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:
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  • 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.
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
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  • Category 1: Fear

    Aspen: unknown fears or worries

    Cherry Plum: fear of losing control of mind, thoughts, temper

    Mimulus: known fears, phobias, shyness

    Red Chestnut: over-concern for others, family members, etc.

    Rock Rose: Panic, Terror

    Rescue Remedy Formula: overall anxiety, stress, fear and trauma

  • Aspen

  • Cherry Plum

  • Mimulus

  • Red Chestnut

  • Rock Rose

  • Category 1: Bach Flower Essences Summary

    Aspen: unknown fears or worries

    Cherry Plum: fear of losing control of mind, thoughts, temper

    Mimulus: known fears, phobias, shyness

    Red Chestnut: over-concern for others, family members, etc.

    Rock Rose: Panic, Terror

    Rescue Remedy Formula: overall anxiety, stress, fear and trauma

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  • Category 2: Uncertainty

    Cerato: lack of confidence in decision making, advice seekers

    Gentian: easily discouraged

    Gorse: feels hopeless, gives-up easily

    Hornbeam: feeling of lack of strength to carry on or accomplish a task

    Scleranthus: indecisive, uncertain in choosing between two choices

    Wild Oat: uncertainty in one’s life path, career, destiny

  • Cerato

  • Gentian

  • Gorse

  • Hornbeam

  • Scleranthus

  • Wild Oat

  • Category 2: Bach Flower Essences Summary

    Cerato: lack of confidence in decision making, advice seekers

    Gentian: easily discouraged

    Gorse: feels hopeless, gives-up easily

    Hornbeam: feeling of lack of strength to carry on or accomplish a task

    Scleranthus: indecisive, uncertain in choosing between two choices

    Wild Oat: uncertainty in one’s life path, career, destiny

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  • Category 3: Lack of Interest in the Present

    Chestnut Bud: fails to learn from past experiences or mistakes

    Clematis: daydreaming, indifference, inattentive

    Honeysuckle: lives in the past

    Mustard: deep gloom for no known reason

    Olive: exhaustion, lack of energy

    White Chestnut: worrisome thoughts, over-thinking

    Wild Rose: resignation lacks ambition

  • Chestnut Bud

  • Clematis

  • Honeysuckle

  • Mustard

  • Olive

  • White Chestnut

  • Wild Rose

  • Category 3: Bach Flower Essences Summary

    Chestnut Bud: fails to learn from past experiences or mistakes

    Clematis: daydreaming, indifference, inattentive

    Honeysuckle: lives in the past

    Mustard: deep gloom for no known reason

    Olive: exhaustion, lack of energy

    White Chestnut: worrisome thoughts, over-thinking

    Wild Rose: resignation lacks ambition

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  • Category 4: Loneliness

    Heather:self-centered, talkative, does not like to be alone

    Impatiens:impatient, hasty

    Water Violet:aloof, proud

  • Heather

  • Impatiens

  • Water Violet

  • Category 4: Bach Flower Essences Summary

    Heather:self-centered, talkative, does not like to be alone

    Impatiens:impatient, hasty

    Water Violet:aloof, proud

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  • Category 5: Over-sensitive to Influences and Ideas

    Agrimony: inner torment behind a brave face

    Centaury: weak-willed, can’t say no

    Holly: envy, hatred, jealousy, suspicion

    Walnut: protection from change and outside influences

  • Agrimony

  • Centaury

  • Holly

  • Walnut

  • Category 5: Bach Flower Essences Summary

    Agrimony: inner torment behind a brave face

    Centaury: weak-willed, can’t say no

    Holly: envy, hatred, jealousy, suspicion

    Walnut: protection from change and outside influences

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  • Category 6: Despondency and Despair

    Crab Apple: self-dislike, feeling unclean

    Elm: overwhelmed

    Larch: lack of confidence, fear of failure

    Oak: exhausted by struggles on

    Pine: feelings of guilt

    Star of Bethlehem: after effect of fright, sorrow and trauma

    Sweet Chestnut: extreme mental anguish, desolation

    Willow: bitterness, resentment

  • Crab Apple

  • Elm

  • Larch

  • Oak

  • Pine

  • Star of Bethlehem

  • Sweet Chestnut

  • Willow

  • Category 6: Bach Flower Essences Summary

    Crab Apple: self-dislike, feeling unclean

    Elm: overwhelmed

    Larch: lack of confidence, fear of failure

    Oak: exhausted by struggles on

    Pine: feelings of guilt

    Star of Bethlehem: after effect of fright, sorrow and trauma

    Sweet Chestnut: extreme mental anguish, desolation

    Willow: bitterness, resentment

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  • Category 7: Over-care for the Welfare of Others

    Beech: critical, judgmental and intolerant

    Chicory: possessive, selfish

    Vervain: fanatical, high-strung

    Vine: domineering, inflexible

    Rock Water: rigidity, self-denial

  • Beech

  • Chicory

  • Vervain

  • Vine

  • Rock Water

  • Category 7: Bach Flower Essences Summary

    Beech: critical, judgmental and intolerant

    Chicory: possessive, selfish

    Vervain: fanatical, high-strung

    Vine: domineering, inflexible

    Rock Water: rigidity, self-denial

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  • You're almost done!

    You're ready to submit your form.
    You will receive email confirmation with the form fields you submitted.
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Animal Aromatherapy Practitioner Certification Course (sm)

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Disclaimer: The information contained in the educational programs and course materials are not intended to diagnose or take the place of professional health care. Always consult with a veterinarian physician in regards to any serious health concerns and issues. The information contained in this handout is for personal awareness only, it is not meant to diagnose or treat any serious health problems/conditions.

Ashi Therapy Ashi Aromatics Inc. © Copyright: Ashi Therapy Ashi Aromatics Inc. All rights reserved.

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