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Bach Flower Therapy Questionnaire

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First Name *

Last Name *

Email

Phone

Please explain the reasons why you decided to start Bach Flowers Therapy (Be as specific as possible): *

INSTRUCTIONS

1. Read each statement and tick EACH that describes how you feel RIGHT NOW. You can tick none or any boxes for each essences.

2. Submit.

3. You will receive an email with a copy of your submited form.

4. Bodywave will get back to you shortly for the next steps.

AGRIMONY

I often hide my feelings behind a facade of cheerfulness

I dislike arguments and often give in to avoid conflict

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

ASPEN

I feel anxious without knowing why

I have a strange fear that something bad will happen

I wake up feeling anxious

BEECH

I easily get annoyed by the habits of others

I often focus on others people's mistakes

I find myself being critical and intolerant of others

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 wrong patterns

CHICORY

I need to be needed and want my loved ones close

I need to be needed and want my loved ones close 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

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 sceptical 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

HEATHER

I am obsessed with my own troubles

dislike being alone and I like to talk

I usually bring conversations back to myself

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 and may procrastinate

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

ROCK WATER

I set high standards for myself

I am strict with my health, work &/or spiritual discipline

I am very self-disciplined, always striving for perfection

SCLERANTHUS

I find it difficult to make decisions when I have 2 options

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, trauma or fright

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 have repeated unwanted thoughts and worries

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

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Existing clients: 0424 113 075

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Location

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West Hindmarsh 5007
South Australia

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