Flower Essence Questionnaire

Complete this questionnaire to begin your journey of holistic, medicinal energetic properties of plants that stimulate the body's ability to regain and maintain healthy function and balance. Click the box next to each question to which you give a definite YES answer. If your answer is NO, or Sometimes, to any question below, leave the box unchecked.

Name *

First Name

Last Name

Email *

example@example.com

Address *

Country *

Address 1 *

Address 2

City *

State *

ZIP code *

Phone Number *

Agrimony

I hide my feelings behind a facade of cheerfulness

I dislike arguments and often give in to conflict

I turn to food, work, alcohol, drugs, etc. when down

Asian Lily

I have trouble letting go of old habbits

I need a new start in life

I've experienced trauma or abuse

Aspen

I feel anxious without knowing why

I have a secret fear that something bad will happen

I wake up feeling anxious

Baby Blue Eyes

I've experienced pain, inappropriate power or abuse from a father figure or men in childhood

I feel tender and sensitive

I feel insecure with intimacy

Beech

I get annoyed by the habits of others

I focus on others' mistakes

I am critical and intolerant

Bleeding Heart

I feel extreme Co-dependance

I feel broken hearted

I am over come by grief

Centaury

I often neglect my own needs to please others

I find it difficult to say "no"

I tend to be easily influenced

Cerato

I constantly second-guess myself

I seek advice, mistrusting my own intuition

I often change my mind out of confusion

Cherry Plum

I'm afraid I might lose control of myself

I have sudden fits of rage

I feel like I"m going crazy

Chestnut Bud

I make the same mistakes over and over

I don't learn from my experience

I keep repeating the same patterns

Chicory

I need to be needed and want my loved ones close

I feel unloved and unappreciated by my family

I easily feel slighted and hurt

Clematis

I often feel spacey and absent-minded

I find myself unable to concentrate for long

I get drowsy and sleep more than necessary

Crab Apple

I am overly concerned with cleanliness

I feel unclean or physically unattractive

I tend to obsess over little things

Day Lily

I have little zest for life

I keep busy to avoid feeling emotional pain

I put undue pressure on myself

Elm

I feel overwhelmed by my responsibilities

I don't cope well under pressure

I have temporarily lost my self-confidence

Gentian

I become discouraged with small setbacks

I am easily disheartened when faced with difficulties

I am often skeptical and pessimistic

Gorse

I feel hopeless, and can't see a way out

I lack faith that things could get better in my life

I feel sullen and depressed

Grape Hyacinth

I have trouble speaking up

I get anxious about having to speak in public

I feel disconnected from my body and mind

Heather

I am obsessed with my own troubles

I dislike being alone and I like to talk

I usually bring conversations back to myself

Hellebore

I have a crippling fear of confrontation

I cannot stop negative thoughts and feelings

I feel like a victim

Holly

I am suspicious of others

I feel discontented and unhappy

I am full of jealousy, mistrust, or hate

Honeysuckle

I'm often homesick for the "way it was"

I think more about the past than the present

I often think about what might have been

Hornbeam

I often feel too tired to face the day ahead

I feel mentally exhausted

I tend to put things off

Impatiens

I find it hard to wait for things

I am impatient and irritable

I prefer to work alone

Larch

I lack self-confidence

I feel inferior and often become discouraged

I never expect anything but failure

Mimulus

I am afraid of things such as spiders, illness, etc.

I am shy, overly sensitive, and modest

I get nervous and embarrassed

Motherwort

I feel nervous and emotional

I am tenderhearted

I have had past conflicts with a mother or mother figure

Mustard

I get depressed without any reason

I feel my moods swinging back and forth

I get gloomy feelings that come and go

Oak

I tend to overwork and keep on in spite of exhaustion

I have a strong sense of duty and never give up

I neglect my own needs in order to complete a task

Olive

I feel completely exhausted, physically and/or mentally

I am totally drained of all energy with no reserves left

I have just been through a long period of illness or stress

Pine

I feel unworthy and inferior

I often feel guilty

I blame myself for everything that goes wrong

Red Chestnut

I am overly concerned and worried about my loved ones

I am distressed and disturbed by other people's problems

I worry that harm may come to those I love

Red Onion

I feel like the odd one out or outcast

I have experienced social isolation

I don't feel like I belong and lonesome

Rock Rose

I sometimes feel terror and panic

I become helpless and frozen when afraid

I suffer from nightmares

Rock Water

I set high standards for myself

I am strict with my health, work and/or spirtual discipline

I am very self-disciplined, always striving for perfection

Scleranthus

I find it difficult to make decisions

I often change my opinions

I have intense mood swings

Star of Bethlehem

I feel devastated due to a recent shock

I am withdrawn due to traumatic events in my life

I have never recovered from loss or fright

Sweet Chestnut

I feel extreme mental or emotional heartache

I have reached the limits of my endurance

I am in complete despair, all hope is gone

Toad Lily

I have an addiction (any kind)

I feel like I have hit rock bottom

I have been exposed to deep hurt, trauma and pain sexually

Vervain

I get high-strung and very intense

I try to convince others of my way of thinking

I am sensitive to injustice, almost fanatical

Vine

I tend to take charge of projects, situations, etc.

I consider myself a natural leader

I am strong-willed, ambitious, and often bossy

Walnut

I am experiencing change in my life: a move, new job etc.

I get drained by people or situations

I want to be free to follow my own ambitions

Water Violet

I give the impression that I'm aloof

I prefer to be alone when overwhelmed

I often don't connect with people.

White Chestnut

I am constantly thinking unwanted thoughts

I relive unhappy events or arguments over and over again

I am unable to sleep at times because I can't stop thinking

Wild Oat

I can't find my path in life

I am drifting in life and lack direction

I am ambitious but don't know what to do

Wild Red Rose

I have been hurt deeply or experience grief and sadness often

My heart feels broken

I feel no joy in life

Willow

I feel resentful and bitter

I have difficulty forgiving and forgetting

I think life is unfair and have a "Poor me attitude"

I prefer a tincture base of *

alcohol (brandy)

apple cider vinegar

I prefer to do my virtual appointment by *

Telephone, using the phone number I've listed above

Video, Tara will share connection details before the appointment

Flower Essence Questionnaire

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Flower Essence Questionnaire

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Contact