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
AnxietyOverwhelmeAnger / ResentmentSadness / griefGuilt / shameLack of motivationFearNumbness
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
I move fast and feel rushedI struggle to slow downI overthink everythingI take on other people’s emotionsI find it hard to express how I feelI put others before myselfI feel disconnected from myselfI lack confidence / self-trustI feel stuck or directionless
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