Flower Essences: Client Background Information Form

Today's date *
Name *
Sex  Female  
Address *
Phone *
Date of birth *
Living alone or with significant other
Ages of children, if any
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?

Please comment on the above areas:
Please give a brief description of your
general state of health.

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


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

(Outlook on life, beliefs and attitudes)

(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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