Children's Flower Essence Consultation
Please complete as the parent or legal guardian. Share only what feels relevant, sensitive questions are optional. Where appropriate invite your child to contribute their own perspective.
Child Details
Child's Full name
*
First Name
Last Name
Date of Birth
*
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent / Guardian Name
*
First Name
Last Name
Relationship to Child
Phone / Email
*
Phone number
Email
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
1. Reasons for the Consultation
What has prompted you to seek flower essence support for your child?
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Please select as many as you like:
Worries / fears
Confidence
Transitions / change
Grief / loss
Emotional overwhelm
Friendships
Sleep related emotions
Other
What is the most important concern or goal at this time?
When did you first notice this? Were there any changes or events around that time?
What positive changes would you hope to see?
2. Your Child as a Person
How would you describe your child's personality, temperament and strengths?
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What makes your child happy, curious, relaxed or confident?
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How does your child usually show feelings such as sadness, frustration, excitement or worry?
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What helps your child feel safe, soothed and understood?
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3. Emotional & Behavioural Patterns
Please select as many as you want
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Separation worries
Shyness
Perfectionism
Sensitivity
Anger / frustration
Withdrawal
Big emotional reactions
Difficulty with change
What situations seem to trigger distress? How does your child respond?
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What usually happens before, during and after a difficult moment?
How does your child communicate their needs, and what support works best?
4. Family, School & Social Life
Who lives with your child? Are there any important family dynamics or recent changes?
How does your child get along with siblings, friends and other significant people?
How is your child experiencing childcare, preschool or school?
Any transitions, bullying concerns, losses or stressful experiences you wish to mention?
5. Daily Rhythms & Sensitivities
Describe sleep, bedtime routines and any relevant worries around sleep.
Describe appetite, daily routines, play, activity and time outdoors.
Any sensory sensitivities (sound, touch, clothing, food, crowds) or emotional preferences?
What activities or routines help your child settle and reconnect?
6. Development, Health & Current Supports
These questions are for context only. Flower essences do not diagnose or treat medical, developmental or mental health conditions.
Any relevant pregnancy, birth or early developmental history you would like to share?
Any health concerns, allergies or sensitivities relevant to the consultation or essence preparation?
Current medications, supplements, herbs or other flower essences (if any).
Does your child see a GP, paediatrician, psychologist, therapist or other professional? Please share what is relevant.
7. Previous Flower Essence Experience
Has your child has flower essences?
First time
Used before
Not sure
If previously used, which essences and what did you notice?
What does your child understand or feel about the consultation? ( if age appropriate?
8. Parent / Guardian Consent
Signature
Date
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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