Custom Flower Essence Form

Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Postal Address - Please include state & postcode

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Are you currently pregnant, breastfeeding, or trying to conceive?
What You Need Support With
What is the one main thing you would like support with right now?
(Please be as specific as possible — e.g. not “stress” but “overwhelm from work and snapping at my partner”)
How long have you been experiencing this?
On a scale of 1–10, how intense does this feel in your body right now?
Emotional Landscape
What emotions come up most strongly around this?
When this shows up, how do you usually respond?
(e.g. shut down, lash out, overthink, withdraw, people please, avoid, etc.)
What thoughts do you notice on repeat during these moments?
Triggers & Patterns
When is this at its worst?
(e.g. time of day, certain environments, around certain people, before your period, etc.)
Is there a specific situation or person that triggers this?
Does this feel familiar or linked to something earlier in your life?
Body & Physical Expression
Where do you feel this in your body?
What physical symptoms are you experiencing (if any)?
(e.g. tension, headaches, gut issues, fatigue, pain, hormonal symptoms, etc.)
How is your sleep currently?
Where are you currently in your cycle?
Do your symptoms shift around your cycle?
Deeper Exploration
If this feeling had a voice, what would it be saying?
What are you currently avoiding or not wanting to face?
What do you feel like you need most right now?
What would life feel like without this issue?
Personality & Tendencies
Which of these do you resonate with most? (tick any)
Support & Awareness
What have you already tried to support this?
Are you currently working with anyone else (coach, therapist, etc.)?
What has helped, even slightly?
Intention Setting
What is your intention for this essence?
Final Notes
Is there anything else you feel is important for me to know?
Should be Empty:

What You Need Support With

Emotional Landscape

Triggers & Patterns

Body & Physical Expression

Deeper Exploration

Personality & Tendencies

Support & Awareness

Intention Setting

Final Notes