Flower Essences – Client Background Information Form

Flower Essences: Client Background Information Form

Today's date *

Name *

Sex

Female

Male

Address *

Phone *

Email

Date of birth *

Living alone or with significant other

Ages of children, if any

Employment/profession

Other main activities
(hobbies and interests)

Have you received flower essences before?
If so, how did you find out about them?
Briefly summarize your experiences with the essences.

What are your main reasons for
wanting to receive flower essences?

To deal with negative and/or painful emotions
For greater spiritual awareness
To help in relationship with others
For physical healing
For greater clarity about my life work and direction
To bring about a more positive attitude toward life
To improve my self-image and feelings about self
For help with an immediate crisis (describe below)
To enhance my creativity and self expression
For long-term inner growth and change
To cope with stress and the demands of life
Other (describe below)

Please comment on the above areas:

Please give a brief description of your
general state of health.

Physical:
(Note any significant medical history,
diet, exercise, energy level, etc.)

Emotional:
(Feelings about self or others, on-going
issues/patterns or areas of conflict)

Mental:
(Outlook on life, beliefs and attitudes)

Spiritual:
(Ultimate sense of purpose,
moral, or religious values)

How do you feel about your work and other
vocational interests?

How do you feel about your work relationships
with others, especially major relationships?

Briefly discuss your family background:

What other therapies or significant growth
experiences are you now undergoing?
Are you taking any medications, or are
you on any significant dietary program?

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