Case Evaluation Form
This form is intended for the client to complete as part of the follow-up interview after
each major cycle of flower essence use. It should be completed in the client’s own handwriting
unless disabled or otherwise unable to do so.
Name: ____________________________________________Phone: _______________________
Time period essences used: __________________________Today’s date: _________________
Which essences did you use? ______________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
How were the essences administered? ___ orally ___ topically other: ________________
Briefly describe the frequency and consistency of use: ________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Please list other therapies engaged in during the time of taking the essences:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Please discuss significant life experiences during this time period: ____________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Please mark one or more categories regarding your results using flower essences:
__resolution of negative or painful emotions
__improvement in relationships with others
__greater clarity about life work and direction
__improvement of self-image and personal
identity
__enhanced creativity and self-expression
__positive lifestyle changes
__reduction in general anxiety or stress
__greater spiritual awareness
__reduction in acute physical symptoms
__generally feeling more positive and resilient
__resolution of a life crisis
__assisting long-term inner growth and change
__marked increase in dreams or related psychic
phenomena
__subtle general improvement, but hard to
capture
__not sure about change due to multi-level factors
__there has been no noticeable improvement or
change to date
Please provide further details on the areas you have marked above:____________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
________________________________________________________________________________
(continued on other side)
Describe your experience of taking the flower essences. Did you notice any direct effects,
or the results in retrospect? _______________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Do you think the flower essences stirred up any new issues in your life? ________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Discuss any inner experiences, such as dreams or insights you had while taking
the essences: ____________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Have others noted differences in your emotions or behavior? Please comment:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Are you continuing to take the flower essences at this time? __________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
This form is intended for the client to complete as part of the follow-up interview after
each major cycle of flower essence use. It should be completed in the client’s own handwriting
unless disabled or otherwise unable to do so.
Name: ____________________________________________Phone: _______________________
Time period essences used: __________________________Today’s date: _________________
Which essences did you use? ______________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
How were the essences administered? ___ orally ___ topically other: ________________
Briefly describe the frequency and consistency of use: ________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Please list other therapies engaged in during the time of taking the essences:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Please discuss significant life experiences during this time period: ____________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Please mark one or more categories regarding your results using flower essences:
__resolution of negative or painful emotions
__improvement in relationships with others
__greater clarity about life work and direction
__improvement of self-image and personal
identity
__enhanced creativity and self-expression
__positive lifestyle changes
__reduction in general anxiety or stress
__greater spiritual awareness
__reduction in acute physical symptoms
__generally feeling more positive and resilient
__resolution of a life crisis
__assisting long-term inner growth and change
__marked increase in dreams or related psychic
phenomena
__subtle general improvement, but hard to
capture
__not sure about change due to multi-level factors
__there has been no noticeable improvement or
change to date
Please provide further details on the areas you have marked above:____________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
________________________________________________________________________________
(continued on other side)
Describe your experience of taking the flower essences. Did you notice any direct effects,
or the results in retrospect? _______________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Do you think the flower essences stirred up any new issues in your life? ________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Discuss any inner experiences, such as dreams or insights you had while taking
the essences: ____________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Have others noted differences in your emotions or behavior? Please comment:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Are you continuing to take the flower essences at this time? __________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________