Intake Form:
Today’s date: ______________________________________
Name: ____________________________________________Sex (M/F): ________________________
Address: __________________________________________ Phone: ___________________________
__________________________________________________ Email: ____________________________
Date and place of birth: _______________________________________________________________
Brief description of living situation including marital status: ______________________________
_____________________________________________________________________________________
Employment/and or daily household responsibilities:_____________________________________
_____________________________________________________________________________________
Please describe your general lifestyle including hobbies, artistic interests and creative expressions:
_______________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Please provide a brief description of your basic state of health, including key medical history,
diet, exercise, physical weight, energy level, etc. Use another piece of paper if needed.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Are you currently engaged in other therapies or significant healing programs? Are you taking
any pharmaceutical medications? Are you following a specific diet or any related health
measure? ___________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
How do your feel about your work and other vocational interests? _________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Are you involved with community or other volunteer activities? ____________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Please comment on your relationships with others, including family, community and work.
Please specify how these relationships might differ from each other — which ones are easier
or more challenging, etc. ______________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Briefly discuss your family of origin and any significant childhood events: __________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Please give an overview of your spiritual values or moral experiences that have shaped your
life: _________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
What aspects of life have been most challenging to date, or have provided recurrent themes
for learning and development? ________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Please share what you’d like to achieve through flower essence therapy, including specific
symptoms and overall goals: __________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
If you wish, you can use another piece of paper to answer the above questions or share anything further about yourself. All information is strictly confidential.
Name: ____________________________________________Sex (M/F): ________________________
Address: __________________________________________ Phone: ___________________________
__________________________________________________ Email: ____________________________
Date and place of birth: _______________________________________________________________
Brief description of living situation including marital status: ______________________________
_____________________________________________________________________________________
Employment/and or daily household responsibilities:_____________________________________
_____________________________________________________________________________________
Please describe your general lifestyle including hobbies, artistic interests and creative expressions:
_______________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Please provide a brief description of your basic state of health, including key medical history,
diet, exercise, physical weight, energy level, etc. Use another piece of paper if needed.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Are you currently engaged in other therapies or significant healing programs? Are you taking
any pharmaceutical medications? Are you following a specific diet or any related health
measure? ___________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
How do your feel about your work and other vocational interests? _________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Are you involved with community or other volunteer activities? ____________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Please comment on your relationships with others, including family, community and work.
Please specify how these relationships might differ from each other — which ones are easier
or more challenging, etc. ______________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Briefly discuss your family of origin and any significant childhood events: __________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Please give an overview of your spiritual values or moral experiences that have shaped your
life: _________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
What aspects of life have been most challenging to date, or have provided recurrent themes
for learning and development? ________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Please share what you’d like to achieve through flower essence therapy, including specific
symptoms and overall goals: __________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
If you wish, you can use another piece of paper to answer the above questions or share anything further about yourself. All information is strictly confidential.