Flower Essence Blend

Flower Essence Blend

Adult Form
Find a quite place to sit and answer these questions truthfully, be completely honest with yourself. Your answers will guide me to your perfectly blended flower essence. Be sure to complete all of the fields so I am able to post your essence to you once payment is received.
Name

First Name Last Name
Date of Birth
Email
example@example.com
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
What is it that you are hoping to achieve with your emotions?
Do you have any reason to be stressed or depressed?
Choose 5-7 boxes that you feel most describes you:

I am frustrated with life I hate change I am always busy and on the go I never want to leave the house I am easily overwhelmed I lack self confidence I am selfish and unaware of people around me I am constantly worried I have been in a trauma/shock situation I am addicted to learning and acquiring knowledge I fear responsibility I have a poor memory I tend to not learn from past experiences I am constantly changing my mind I am clumsy I am easily discouraged I feel exhausted I hold onto grudges I am filled with hatred I have an inability to resolve problems I am easily bored I have mood swings I have a lack of purpose and direction in life I constantly compare myself to others I am a negative person and find myself constantly complaining I need physical healing I feel lonely and isolated I feel helpless and hopeless I am so critical of everything all the time I have phobias I am OCD

How you feel in your relationships

Yes

Sometimes

Do you have an inability to enjoy sex?

Do you have self loathing?

Do you have a fear of intimacy?

Are you shy and insecure?

Do you resent others?

Do you have low self esteem?

Do you dislike being touched?

Are you emotionally closed in relationships?

Do you have obsessive thoughts?

Are you broken hearted?

Do you have difficulty committing to relationships?

Are you excessively generous?

Are you over sensitive?

Are you reliant in others?

Are you hot headed and tempered?

Do you have trouble letting go of past relationships?

Are you trying to conceive?

By submitting this form you are giving consent for Hinterland Naturopathy to collect and store your personal information as a part of your case file. This information is necessary for proper and effective Flower Essence Remedy.

All your personal information is treated with strict confidence.

You understand that a Naturopath doesn't diagnose illness, disease or any other physical and mental disorder and we do not prescribe medical treatment.

Payment in full of $25 includes postage must be made before dispensing of Flower Essence.

My Products

Flower Essence Blend $ 25.00 AUD

Total $ 0.00 AUD

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Date	Postal Code

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