EmailMe Form - BACH FLOWERS

BACH FLOWERS

WITH APPOINTMENT ONLY

In the section (Description of the current situation), take the time to describe the situation for which you want to prepare personalities of Bach Flowers.

Then check only the statement (s) that describe how you feel in this specific situation in your life. If the list of statements does not describe your current situation well, take the time to write the list of emotions experienced in the section (Description of the current situation). This enumeration will help me prepare your custom blend of Bach Flowers.

Complete the * sections. The information collected in this form will be used to complete your client's file.

I'm a new client :
yes
no
(For new clients, there is a $10 file opening fee.)
Last name *
First name *
email *
Phone number *
### - ### - ####
Street *
Town *
Postal code *
Date of Birth : *
DD = day, MM = month, YYYY =year
Exemple : 24/02/1975
Description of the current situation : *
MARK ONLY THE STATEMENTS THAT APPLY TO YOUR SITUATION MENTIONED IN THE "DESCRIPTION OF THE SITUATION" SECTION.

Fear
(Aspen) inexplicable and vague anxieties, premonitions, secret fears of impending disaster
(Cherry Plum) fear of falling inside, falling into madness, committing an irreparable act, uncontrollable crises of violence
(Mimulus) specific fear whose cause is known
(Red Chestnut) excessive worries and fears for others.
(Rock rose) feeling of fear and panic; state of acute fear
Loneliness
(Water violet) per moment: reserved, proud restraint, feeling of superiority in isolation
(Impatiens) impatient, easily irritated, excessive reactions
(Heather) egotism, fully preoccupied with self, constant need of the public, (dependent child)
Insufficient interest in present circumstances
(Clematis) dreamer; is always elsewhere in thought; shows little interest in what is happening around him
(Honeysuckle) Nostalgie du passé, regrets pour des faits passés, ne vit pas dans le présent
(Wild rose) total disinterest, apathy, resignation, inward surrender
(Olive) total exhaustion, extreme fatigue of body and mind
(White Chestnut) thoughts that turn tirelessly in the head (always present), monologue and inner dialogues
(Mustard) prondond melancholy attacks that come and go for no apparent reason
(Chestnut bud) always repeats the same mistakes because one does not really integrate his experiences and because they do not serve as a lesson
Despondency or Despair
(Crab apple) to feel inside externally soiled, unclean or infected, see too small details
(Elm) temporary feeling of not being up to the task or responsibilities
(Larch) waiting for failure due to lack of self-confidence; inferiority complex
(Oak) defeated fighter, exhausted but who continues courageously and never gives up
(Pine) self accusation, feelings of guilt, discouragement
(Sweet Chestnut) absolute despair, being at the limit of human endurance
(Star of Bethleem) physical, phsychic or spiritual shock, recent or ancient; to comfort the soul and soothe pain
(Willow) resentment, internal bitterness, victim of his destiny
Over-sensitivity to influences and ideas
(Agrimony) hiding disturbing thoughts and inner restlessness behind a facade of cheerfulness and relaxation
(Centaury) weakness of own will, exaggerated reaction to the will of others, easily lets exploit its natural goodness, can’t say no
(Holly) jealousy, distrust, feelings of hatred and envy on all levels
(Walnut) doubt, impressionable and irresolution at the beginning of an important new phase of life; Walnut, the quintessence that makes it possible to «take the step»
Over-care for welfare of others
(Beech) mania of criticism, arrogance, intolerance, judging others without any attempt at understanding
(Chicory) possessive personality who likes to manipulate others and over-interfere in their affairs; expects total affection from those around her and pities herself as soon as she does not manage to pass her will
(Rock water) harsh and rigid conceptions, repression of vital needs, excessive severity towards oneself
(Vervain) overexertion by excess of zeal for a good cause, excitement, fanaticism
(Vine) domination, ambitious, tyrannical
For Those Who Suffer Uncertainty
(Cerato) self-confidence in his own intuition
(Schleranthus) unsolved, versatile, subject to sudden mood swings and changes of opinion
(Gentian) skeptical, doubtful of everything, pessimistic, easily loses courage
(Gorse) without hope, totally discouraged, feeling that it is no longer useful
(Hornbeam) fatigue, temporary or lasting mental weariness
(Wildoat) inaccuracy in his goals, dissatisfaction because one does not see his task assigned by life (mission)
two possible options: *
15ml for $20
30ml for $25
If I need to clarify some things about the current situation, before planning your appointment, how is it best to contact you? *
email
phone
text message
Facebook
For texting, please tell me which mobile phone number is best for sending you your appointment confirmation.
The best time to pick up your costum blend: *
am
pm
evening
my preferences
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
For payment, I choose: *
check
cash
credit card
Interac transfer
Apple Pay
Google Pay
For Interac credit transfer, use the following email: rohrei@yahoo.ca
Naturotherapy receipt? *
I need one.
I don't need one.
further information:

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