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 NameLast Name
Date of Birth
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone 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 lifeI hate changeI am always busy and on the goI never want to leave the houseI am easily overwhelmedI lack self confidenceI am selfish and unaware of people around meI am constantly worriedI have been in a trauma/shock situationI am addicted to learning and acquiring knowledgeI fear responsibilityI have a poor memoryI tend to not learn from past experiencesI am constantly changing my mindI am clumsyI am easily discouragedI feel exhaustedI hold onto grudgesI am filled with hatredI have an inability to resolve problemsI am easily boredI have mood swingsI have a lack of purpose and direction in lifeI constantly compare myself to othersI am a negative person and find myself constantly complainingI need physical healingI feel lonely and isolatedI feel helpless and hopelessI am so critical of everything all the timeI have phobiasI am OCD

How you feel in your relationships

	Yes	No	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

Total $0.00

Credit Card

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