Flower Essences Consultation
Adult
Appointment & Personal Details
Please answer only what you feel comfortable sharing. You may leave questions blank and discuss them during your consultation
Appointment Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Appointment Time
Hour Minutes
AM
PM
AM/PM Option
Appointment Type
*
Initial consultation
Follow - up
In person
Online
Phone
Name
*
First Name
Last Name
Preferred Name
Name
Pronouns
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Mobile Number
*
Email
*
example@example.com
Preferred contact method
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency contact
Name
Phone number
1. Your reasons for seeking Flower Essences
What would you most like help with at this time?
*
Please select as many as you would like
*
Emotional Wellbeing
Stress / coping
Relationships
Self image / confidence
Life Direction
Creativity
Transitions / grief
Personal / spiritual growth
Positive outlook
Other
What is your main priority or challenge right now?
*
When did this begin? Was there a memorable event or change around that time?
What would you like to feel, understand or experience differently?
*
2. Your Emotional Landscape
Please select as many as you want.
*
Worry / fear
Overwhelm
Sadness / grief
Anger / frustration
Low motivation
Loneliness
Sensitivity
Uncertainty / indecision
Which feeling is most difficult at present? When or where do you notice it most?
*
Current stress level 0 - 10
*
Main sources of stress and people or activities that support you:
How often do you experience anxiousness?
Often
Sometimes
Seldom
How often do you experience low mood?
Often
Sometimes
Seldom
How would you describe your current sense of hope, joy, contentment and confidence?
Low
Moderate
Strong
Varies
Anything else you would like to share about your emotions or self-image?
3. Life, Work & Relationships
Your work, main responsibilities and how you feel about them:
*
Hobbies, interests, recreation and sources of creativity or enjoyment:
*
Important relationships, family dynamics or relationship challenges:
*
Is there a longing, goal or direction in life that feels important to you?
*
4. Personal Background & Growth
Are there meaningful childhood memories, family experiences or life events you would like to share?
How would you describe your current outlook, beliefs, values or sense of purpose?
*
Are you currently exploring any other personal-growth practices, therapies or spiritual practices?
*
5. General Wellbeing & Current Supports
These questions providde context; a flower essence consultation does not diagnose or treat physical or mental health conditions.
How would you describe your general physical health, energy, sleep, movement and nutrition?
*
Any recurring physical concerns or significant health history you wish to disclose?
Current medications, supplements, herbs, flower essences or special dietary practices:
*
Health professionals, counsellors or other supports you are currently working with:
*
Allergies, sensitivities or prefernces for alcohol-free preparations:
*
6. Previous Experience & Preferences
Have you used flower essences before?
*
Yes
No
Unsure
If yes, which essences or blends did you sue and what was your experience?
How did you hear about flower essences / Honovi Harmonised Health?
Anything you would prefer the practitioner to know before your appointment?
7. Informed Consent
Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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