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Appointment Request Form

Appointment Request Form

I am so excited to support you along your journey! Please use this form to tell me a little bit about yourself. There are 12 questions, but they’re generally very simple, so don’t panic! The form, once completed, will be sent directly to me. Once I receive it, I will let you know if I think we will be a good match (don’t worry—this is not about me judging you! I just want to make sure I won’t be wasting your time and resources if it’s looking like I will not be the best person to help you.). I will then send you my schedule and booking program so you can book your appointment. Thank you!!
12Questions
  • 1
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  • 2
    I ask this just so I have a sense of your age—but you can never be too young or too old to use flower essences; even babies can benefit from them!
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  • 3
    Please enter the phone number you would like me to call when it is time for your appointment.
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  • 4
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  • 5
    I ask for your address so I will be able to send you your dosage bottle after our session.
    United States
    • Please Select
    • Afghanistan
    • Albania
    • Algeria
    • American Samoa
    • Andorra
    • Angola
    • Anguilla
    • Antigua and Barbuda
    • Argentina
    • Armenia
    • Aruba
    • Australia
    • Austria
    • Azerbaijan
    • The Bahamas
    • Bahrain
    • Bangladesh
    • Barbados
    • Belarus
    • Belgium
    • Belize
    • Benin
    • Bermuda
    • Bhutan
    • Bolivia
    • Bosnia and Herzegovina
    • Botswana
    • Brazil
    • Brunei
    • Bulgaria
    • Burkina Faso
    • Burundi
    • Cambodia
    • Cameroon
    • Canada
    • Cape Verde
    • Cayman Islands
    • Central African Republic
    • Chad
    • Chile
    • China
    • Christmas Island
    • Cocos (Keeling) Islands
    • Colombia
    • Comoros
    • Congo
    • Cook Islands
    • Costa Rica
    • Cote d'Ivoire
    • Croatia
    • Cuba
    • Curaçao
    • Cyprus
    • Czech Republic
    • Democratic Republic of the Congo
    • Denmark
    • Djibouti
    • Dominica
    • Dominican Republic
    • Ecuador
    • Egypt
    • El Salvador
    • Equatorial Guinea
    • Eritrea
    • Estonia
    • Ethiopia
    • Falkland Islands
    • Faroe Islands
    • Fiji
    • Finland
    • France
    • French Polynesia
    • Gabon
    • The Gambia
    • Georgia
    • Germany
    • Ghana
    • Gibraltar
    • Greece
    • Greenland
    • Grenada
    • Guadeloupe
    • Guam
    • Guatemala
    • Guernsey
    • Guinea
    • Guinea-Bissau
    • Guyana
    • Haiti
    • Honduras
    • Hong Kong
    • Hungary
    • Iceland
    • India
    • Indonesia
    • Iran
    • Iraq
    • Ireland
    • Israel
    • Italy
    • Jamaica
    • Japan
    • Jersey
    • Jordan
    • Kazakhstan
    • Kenya
    • Kiribati
    • North Korea
    • South Korea
    • Kosovo
    • Kuwait
    • Kyrgyzstan
    • Laos
    • Latvia
    • Lebanon
    • Lesotho
    • Liberia
    • Libya
    • Liechtenstein
    • Lithuania
    • Luxembourg
    • Macau
    • Macedonia
    • Madagascar
    • Malawi
    • Malaysia
    • Maldives
    • Mali
    • Malta
    • Marshall Islands
    • Martinique
    • Mauritania
    • Mauritius
    • Mayotte
    • Mexico
    • Micronesia
    • Moldova
    • Monaco
    • Mongolia
    • Montenegro
    • Montserrat
    • Morocco
    • Mozambique
    • Myanmar
    • Nagorno-Karabakh
    • Namibia
    • Nauru
    • Nepal
    • Netherlands
    • Netherlands Antilles
    • New Caledonia
    • New Zealand
    • Nicaragua
    • Niger
    • Nigeria
    • Niue
    • Norfolk Island
    • Turkish Republic of Northern Cyprus
    • Northern Mariana
    • Norway
    • Oman
    • Pakistan
    • Palau
    • Palestine
    • Panama
    • Papua New Guinea
    • Paraguay
    • Peru
    • Philippines
    • Pitcairn Islands
    • Poland
    • Portugal
    • Puerto Rico
    • Qatar
    • Republic of the Congo
    • Romania
    • Russia
    • Rwanda
    • Saint Barthelemy
    • Saint Helena
    • Saint Kitts and Nevis
    • Saint Lucia
    • Saint Martin
    • Saint Pierre and Miquelon
    • Saint Vincent and the Grenadines
    • Samoa
    • San Marino
    • Sao Tome and Principe
    • Saudi Arabia
    • Senegal
    • Serbia
    • Seychelles
    • Sierra Leone
    • Singapore
    • Slovakia
    • Slovenia
    • Solomon Islands
    • Somalia
    • Somaliland
    • South Africa
    • South Ossetia
    • South Sudan
    • Spain
    • Sri Lanka
    • Sudan
    • Suriname
    • Svalbard
    • eSwatini
    • Sweden
    • Switzerland
    • Syria
    • Taiwan
    • Tajikistan
    • Tanzania
    • Thailand
    • Timor-Leste
    • Togo
    • Tokelau
    • Tonga
    • Transnistria Pridnestrovie
    • Trinidad and Tobago
    • Tristan da Cunha
    • Tunisia
    • Turkey
    • Turkmenistan
    • Turks and Caicos Islands
    • Tuvalu
    • Uganda
    • Ukraine
    • United Arab Emirates
    • United Kingdom
    • United States
    • Uruguay
    • Uzbekistan
    • Vanuatu
    • Vatican City
    • Venezuela
    • Vietnam
    • British Virgin Islands
    • Isle of Man
    • US Virgin Islands
    • Wallis and Futuna
    • Western Sahara
    • Yemen
    • Zambia
    • Zimbabwe
    • Other
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  • 6
    What is your time zone? I ask for this information to make sure that we are both on the same page about appointment times etc. Please note that I am in EST, so the time slots on my schedule reflect that.
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  • 7
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  • 8
    We will spend more time discussing this in our session, so don’t worry about telling me your entire life history—just what you feel is important. And remember: flower essences do not interfere with medications, so please do not let this section stop you from continuing if you are using any. It just helps me to have some sense of what we are looking at in advance so I am not caught off guard!
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  • 9
    Kosher brandy is alcoholic; red shiso (from Green Hope Farm) is not. This is a matter of personal preference. Whichever stabilizer you choose will fill approximately 1/3 of the bottle; the rest will be filled with drops of your flower essences and water.
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  • 10
    I hereby release Leah, Flower Essence Practitioner, and Blooming Neshama, from any legal responsibility for any physical, mental, or emotional conditions or symptoms which may be perceived as resulting from the Flower Essence treatment I receive from her. I understand that Flower Essences are safe, non-toxic, natural remedies which, in themselves, have no side-effects. I also understand that Flower Essence consultations do not address the cure for physical symptoms. I have been advised by Leah to consult with my physician for the treatment of any physical or emotional symptoms which may be of concern to me before, during, or after my Flower Essence Consultations.
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  • 11
    Blooming Neshama is committed to providing exceptional service. Unfortunately, when one client cancels their appointment without giving adequate notice, they prevent another client from being seen. This is both unfair to the other client who would like to be seen, and also unfair to me as a practitioner, as it leaves a gap in the schedule that could have been filled with appropriate notice. Please email me at bloomingneshama@gmail.com by 2:00 p.m. on the day prior to your scheduled appointment to notify me of any changes or cancellations. To cancel a Monday appointment, please email me by 12:00 p.m. on Friday. If prior notification is not given, you will be charged $36 for the missed appointment.
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