Flower Essence Questionnaire

Flower Essence Questionnaire

Complete this questionnaire to begin your journey of holistic, medicinal energetic properties of plants that stimulate the body's ability to regain and maintain healthy function and balance. Click the box next to each question to which you give a definite YES answer. If your answer is NO, or Sometimes, to any question below, leave the box unchecked.
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Agrimony

I hide my feelings behind a facade of cheerfulnessI dislike arguments and often give in to conflictI turn to food, work, alcohol, drugs, etc. when down
Asian Lily

I have trouble letting go of old habbitsI need a new start in lifeIve experienced trauma or abuse
Aspen

I feel anxious without knowing whyI have a secret fear that something bad will happenI wake up feeling anxious
Baby Blue Eyes

I've experienced pain, inappropriate power or abuse from a father figure or men in childhoodI feel tender and sensitiveI feel insecure with intimacy
Beech

I get annoyed by the habits of othersI focus on others' mistakesI am critical and intolerant
Bleeding Heart

I feel extreme Co-dependanceI feel broken heartedI am over come by grief
Centaury

I often neglect my own needs to please othersI find it difficult to say "no"I tend to be easily influenced
Cerato

I constantly second-guess myselfI seek advice, mistrusting my own intuitionI often change my mind out of confusion
Cherry Plum

I'm afraid I might lose control of myselfI have sudden fits of rageI feel like I"m going crazy
Chestnut Bud

I make the same mistakes over and overI don't learn from my experienceI keep repeating the same patterns
Chicory

I need to be needed and want my loved ones closeI feel unloved and unappreciated by my familyI easily feel slighted and hurt
Clematis

I often feel spacey and absent-mindedI find myself unable to concentrate for longI get drowsy and sleep more than necessary
Crab Apple

I am overly concerned with cleanlinessI feel unclean or physically unatractiveI tend to obsess over little things
Day Lily

I have little zest for lifeI keep busy to avoid feeling emotional painI put undue pressure on myself
Elm

I feel overwhelmed by my responsibilitiesI don't cope well under pressureI have temporarily lost my self-confidence
Gentian

I become discouraged with small setbacksI am easily disheartened when faced with difficultiesI am often skeptical and pessimistic
Gorse

I feel hopeless, and can't see a way outI lack faith that things could get better in my lifeI feel sullen and depressed
Grape Hycinth

I have trouble speaking upI get anxious about having to speak in publicI feel disconnected from my body and mind
Heather

I am obsessed with my own troublesI dislike being alone and I like to talkI usually bring conversations back to myself
Hellebore

I have a crippling fear of confrontationI cannot stop negative thoughts and feelingsI feel like a victim
Holly

I am suspicious of othersI feel discontented and unhappyI am full of jealousy, mistrust, or hate
Honeysuckle

I'm often homesick for the "way it was"I think more about the past than the presentI often think about what might have been
Hornbeam

I often feel too tired to face the day aheadI feel mentally exhaustedI tend to put things off
Impatiens

I find it hard to wait for thingsI am impatient and irritableI prefer to work alone
Larch

I lack self-confidenceI feel inferior and often become discouragedI never expect anything but failure
Mimulus

I am afraid of things such as spiders, illness, ec.I am shy, overly sensitive, and modestI get nervous and embarrassed
Motherwort

I feel nervous and emotionalI am tenderheartedI have had past conflicts with a mother or mother figureType option 4
Mustard

I get depressed without any reasonI feel my moods swinging back and forthI get gloomy feelings that come and go
Oak

I tend to overwork and keep on in spite of exhaustionI have a strong sense of duty and never give upI neglect my own needs in order to complete a task
Olive

I feel completely exhausted, physically and/or mentallyI am totally drained of all energy with no reserves leftI have just been through a long period of illness or stress
Pine

I feel unworthy and inferiorI often feel guiltyI blame myself for everything that goes wrong
Red Chestnut

I am overly concerned and worried about my loved onesI am distressed and disturbed by other people's problemsI worry that harm may come to those I love
Red Onion

I feel like the odd one out or outcastI have experienced social isolationI don't feel like I belong and lonesome
Rock Rose

I sometimes feel terror and panicI become helpless and frozen when afraidI suffer from nightmares
Rock Water

I set high standards for myselfI am strict with my health, work and/or spirtual disciplineI am very self-disciplined, always striving for perfection
Scleranthus

I find it difficult to make decisionsI often change my opinionsI have intense mood swings
Star of Bethlehem

I feel devastated due to a recent shockI am withdrawn due to traumatic events in my lifeI have never recovered from loss or fright
Sweet Chestnut

I feel extreme mental or emotional heartacheI have reached the limits of my enduranceI am in complete despair, all hope is gone
Toad Lily

I have an addiction (any kind)I feel like I have hit rock bottomI have been exposed to deep hurt, trauma and pain sexually
Vervain

I get high-strung and very intenseI try to convince others of my way of thinkingI am sensitive to injustice, almost fanatical
Vine

I tend to take charge of projects, situations, etc.I consider myself a natural leaderI am strong-willed, ambitious, and often bossy
Walnut

I am experiencing change in my life: a move, new job etc.I get drained by people or situationsI want to be free to follow my own ambitions
Water Violet

I give the impression that I'm aloofI prefer to be alone when overwhelmedI often don't connect with people.
White Chestnut

I am constantly thinking unwanted thoughtsI relive unhappy events or arguments over and over againI am unable to sleep at times because I can't stop thinking
Wild Oat

I can't find my path in lifeI am drifting in life and lack directionI am ambitious but don't know what to do
Wild Red Rose

I have been hurt deeply or experience grief and sadness oftenMy heart feels brokenI feel no joy in life
Willow

I feel resentful and bitterI have difficulty forgiving and forgettingI think life is unfair and have a "Poor me attitude"
I prefer a tincture base of:*

alcohol (brandy)apple cider vinegar
I prefer to do my virtual appointment by*

Telephone, using the phone number I've listed aboveVideo, Tara will share connection details before the appointment
Please verify that you are human*
Spa Schwa values your privacy. We do not rent, sell, or share personal information about you with other people or non-affiliated companies. Please visit our website for more information on our privacy policy.
Should be Empty: