FREE Mental-Emotional Survey

Mental-Emotional Survey

HolistiCare Mind Body Consulting, El Paso, TX, USA Https://www.holisticare.online
Discover real and clear causes of mental-emotional stress and distress by taking this survey. You will receive a summary of your responses to the email that you provide.

The purpose of this survey is to gather information related to current chronic and/or acute symptoms in order to know yourself better and possibly to help your Certified Natural Health Practitioner understand your current state more clearly to help you better.

You will be provided with an opportunity to request a call back (if you choose) to answer questions you may have about your responses to this survey.
Client Name *

First Name Middle Name Last Name
Age *
Name of Parent or Guardian if client is underage

First Name Middle Name Last Name
Contact Number *

Area Code Phone Number
Email *
example@example.com

Read each statement in each section then check all that apply to you.

In each section (of 3 statements) you can check all, none or any number of statements that apply to you.

If you are filling out the survey for a child, check all that apply to the child.
AGRIMONY

I hide my feelings behind a facade of cheerfulness I dislike arguments and give in to avoid conflict I turn to food, drugs, etc., when feeling down
ASPEN

I feel anxious (anxiety) without knowing why I have a secret fear that something bad will happen I wake up feeling anxious
BEECH

I get annoyed by the habits of others I focus on other’s mistakes I am critical and intolerant
CENTAURY

I often neglect my own needs to please others I find it difficult to say NO I tend to be easily influenced
CERATO

I constantly second guess myself I seek advice, mistrusting my own intuition I often change my mind out of confusion
CHERRY PLUM

I’m afraid I might lose control of myself I have sudden fits of rage I feel like I’m going crazy
CHESTNUT BUD

I make the same mistakes over and over I don’t learn from my experience I keep repeating the same patterns
CHICORY

I need to be needed and want loved ones close I feel unappreciated and unloved by my family I easily feel slighted and hurt
CLEMATIS

I often feel spacey and absent-minded I find myself unable to concentrate for long I get drowsy and sleep more than necessary
CRAB APPLE

I am overly concerned with cleanliness I feel unclean and/or physically unattractive I tend to obsess over little things
ELM

I feel overwhelmed by my responsibilities I don’t cope well under pressure I have temporarily lost my self-confidence
GENTIAN

I become discouraged by small setbacks I am easily disheartened in difficult situations I am often skeptical and/or pessimistic
GORSE

I feel hopeless and can’t see a way out I lost all faith that things can get any better I feel sullen and depressed
HEATHER

I am obsessed with my own troubles I dislike being alone and I like to talk I usually bring conversations back to myself
HOLLY

I am suspicious of others I feel discontented and unhappy I am full of envy, jealousy, mistrust, hate, vengefulness
HONEYSUCKLE

I am often homesick for the way it was I think more about the past than the present I often think what might have been
HORNBEAM

I often feel too tired to face the day I feel mentally exhausted and lack energy I tend to put things off (procrastination)
IMPATIENS

I find it hard to wait for things or people I am impatient and irritable I’d rather work alone to avoid time wasted, interference.
LARCH

I lack self-confidence and self-worth I feel inferior and often become discouraged I expect to fail / I expect failure
MIMULUS

I’m afraid of things like spiders, illness, death, etc. I am shy, overly sensitive and modest I get nervous and embarrassed
MUSTARD

I get depressed without any reason I feel my moods swinging back and forth I get gloomy feelings that come and go
OAK

I tend to overwork and keep working in spite of exhaustion I have a strong sense of duty and never give up I neglect my own needs in order to complete a task
OLIVE

I feel completely exhausted physically and mentally I am totally drained of energy with no reserves left I’ve just been through a long period of illness or stress
PINE

I often feel guilty I blame myself for everything that goes wrong I apologize for everything and say “I’m sorry”
RED CHESTNUT

I’m overly concerned & worried about my loved ones I worry obsessively about my health I’m a hypochondriac (irrational fear of disease)
ROCK ROSE

I sometimes feel terror and panic I become helpless and frozen when afraid I suffer from nightmares
ROCK WATER

I set high standards for myself and others I am strict with my health, work, family, etc. I am very self-disciplined, always striving for perfection
SCLERANTHUS

I find it difficult to make decisions I often change my mind/opinion I cannot make up my mind
STAR OF BETHLEHEM

I feel devastated due to recent or past shock/trauma I’m withdrawn due to traumatic events in my life I have never recovered from loss or fright
SWEET CHESTNUT

I feel extreme mental/emotional heartache I have reached the limits of my endurance I am in complete despair & all hope is gone
VERVAIN

I get high-strung and intense I persuade and try to convince others I am sensitive to injustice, almost fanatical
VINE

I tend to take charge of projects, situations, etc. I tend to be domineering without regard for others I am strong-willed, ambitious and bossy
WALNUT

I’m experiencing change in life: a move, new job, etc. I’m finding it difficult to move forward I want to be free to follow my own ambitions
WATER VIOLET

I give the impression that I am aloof, disinterested, distant I prefer to be alone when overwhelmed I often don’t/can’t connect with people
WHITE CHESTNUT

I’m constantly thinking and can’t stop thinking I repeatedly relive unhappy events or arguments I’m unable to sleep because I can’t stop thinking
WILD OAT

I can’t find my path in life I’m drifting in life and lack direction I’m ambitious but don’t know what to do
WILD ROSE

I’m apathetic and resigned to whatever happens I have the attitude “it doesn’t matter anyhow” I feel no joy in life
WILLOW

I feel resentful and bitter I have difficult forgiving and forgetting I feel life is unfair and have a “poor me” attitude
End of Survey !

Please choose from the options below and press "submit" to finish.
CALL BACK REQUEST

YES. Please call me back. I am tired of feeling like this and I need help. I am ready for therapy. NO. Don't call me. I don't need therapy. I know I need help. I will book myself an appointment on your website when I'm ready. I know I need help. I will call you directly at 915-329-1822 or 915-843-0768 when I'm ready.
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Mental-Emotional Survey

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