| All fields required unless
marked optional. |
| Please supply the
requested information in the following blocks. All
information received will be used solely for the purpose
of this consultation and will remain confidential. |
Name Age
Sex | Male Female |
| Employment/Occupation
Marital Status |
| Address 1 |
| Address 2
(optional) |
| City |
| State |
| Zip |
| Country |
| Phone (123-456-7890 x123)
format |
| Fax
(123-456-7890)(optional) |
Email address (me@domain.com)
Date
(mm/dd/yy) |
| 1. If you have ever taken
flower essences before, please summarize your experience
with them. |
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| 2. Please list any other
health care practices that you are currently engaged in
or have experienced in the past and briefly describe
their effects. Also list any medications you are
taking. |
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| 3. Tell me about your
general state of health and family background. |
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| 4. An important part of
flower essence therapy is establishing short and long
term goals for our work together. Please describe you
priorities for health and well-being in the following
categories. |
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| 5. What are your
priorities for our first consultation? |
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