Sally Broadhurst Flower Essence Intake Form

Sally Broadhurst Flower Essence Intake Form
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Are you currently seeing any other health care providers? (Doctors, Chiropractors, Acupuncturist, Massage Therapists, Specialists, etc.):
Do you have any diagnosed medical conditions allergies or sensitivities? (e.g., foods, medications, herbs)
Are you currently taking any medications or supplements? If yes please list here:
How did you hear about me?*
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Would you like a dose of wellbeing in your inbox? (no side effects, promise, just a semi-regular newsletter)*

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Have you used Flower Essences before:

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Health + Wellbeing Overview
Please describe what’s been most present for you lately — emotionally, mentally, or physically (What’s feeling challenging, out of balance, or in need of support?)
Is there anything significant happening in your daily life right now — such as work, relationships, finances, self-esteem/worth, etc that feels relevant to your wellbeing?
Are there any recurring patterns, emotions, or themes that you notice showing up for you over time?
What is your main goal or intention that you would you like support with in this session? (Please share anything else that you feel I should know)
How would you rate your current stress level? (scale 1–10)

Informed Consent for Flower Essence Consultation:
I understand and acknowledge the following:

Nature of Flower Essence Therapy:
- Flower essences are energetic remedies that work on an emotional and energetic level to support wellbeing
- Flower essences address emotional and energetic wellbeing and are not intended to diagnose, treat, or cure any disease
- Flower essences are safe to use alongside medications and supplements
- Flower essence therapy is complementary to, not a replacement for, conventional medical care
Preparation Method:
- Flower essences are preserved in an alcohol base (brandy)
- I understand the remedies contain alcohol and will inform the practitioner if I have any concerns or contraindications regarding alcohol consumption
My Responsibilities:
- I will inform my healthcare provider(s) about any complementary therapies I am receiving if relevant to my care
- I will not cease or alter any prescribed medications or treatments without consulting my prescribing practitioner
- I will inform the practitioner of any significant health conditions, allergies, pregnancy, or changes to my health status
Privacy:
- My personal health information will be kept confidential and not released to third parties without my written consent, except where required by law
Cancellation Policy:
- If you need to cancel or reschedule, please give me at least 24 hours notice for a full refund or to reschedule. Cancellations with less than 24 hours notice will forfeit the session fee.
Consent
I confirm that I have read and understood the above and consent to flower essence consultation and treatment:
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Sally Broadhurst Flower Essence Intake Form

Health + Wellbeing Overview

Informed Consent for Flower Essence Consultation: