Flower Essence Therapy Intake Form

Wildflower Clinic- Flower Essence Therapy Intake Form

Please fill in the form below before your therapy session!
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Sex

MaleFemaleDo not identify
Phone Number*

Area CodePhone Number
E-mail*

General Health Questions
What is your current living situation/ marital status?
Describe your current hobbies, lifestyle, and creative interests
What are your emotional and spiritual goals? What would you like to achieve with Flower Essence Therapy?
What are your current blockages or resistance to obtaining these goals?
Are you currently undergoing another healing program/ protocol?
Please comment on your personal relationships with your family, co-workers, and friends. Are some of these relationships easier to be a part of? Please explain:
Please describe any important childhood experience, including any family dynamics growing up that have shaped who you are today
Please describe any community, social, or volunteer work that you are currently involved in or would like to be involved in in the future
What do you feel is the root of your imbalance?

Overview of Health
Rate your energy Level (1-10) 10 being the most abundant.
Rate your overall emotional well-being (1-10) 10 being most stable.
Do you have any digestion or elimination issues?
Do you experience headaches?
Do you suffer from allergies, if so, which ones?
Do you experience sleep disturbances?
How many hours of sleep do you get a night?
Please list any medications you are currently taking.
Please feel free to share more experiences or any further personal information in a separate sheet of paper, all responses are completely confidential.
Should be Empty:

Wildflower Clinic- Flower Essence Therapy Intake Form