Flower Essence Questionnaire

Name Date of birth Sex



Tel. No.

Married/long-term partnership Separated or Divorced Single

If you have children please list their ages and sex.


Medical history (i.e., chronic illnesses, any major surgery).

Describe the condition or situation which you would like to change with the help of our counseling service.

HOW DO YOU FEEL ABOUT: (In answering please focus on problem areas or difficulties, and be as specific as possible. i.e., "My mother and I haven't spoken in 20 years" tells us more than "I don't get along with my family. Ask yourself, as you consider the following areas, "If there were one thing I could change, what would it be?")

Your present occupation (i.e, bored, frustrated, difficulties with fellow employees or boss)

Your relationships with members of your family (describe any problems with particular individuals)

Your marital or partnership relationship (if none is that a problem?)

Your emotional health, including degree of self-esteem, decisiveness, intuition, resentment, anxiety-- seems to stand between you and happiness.)

Your spiritual development

Have you ever used flower essences before?

If so, and you and remember the essences you took, please list them.

How did you benefit from the use of flower essences?

Have you ever used essential oils before?

If so, and you remember the oils you took, please list them

How did you benefit from the use of essential oils?

If there is anything else you would like to tell us, please say it here.

So that we don't recommend a healing modality or practice you already use, please:

List,if any, the alternative healing modalities you've experienced (Herbs,homeopathy, past life regression, etc.), and and the amount of experience (i.e, ;I take herbs daily;).

List,if any, the spiritual tools you use (meditation, affirmations, yoga, visualization, crystals, Reiki), and the frequency with which you use them ("I give myself a Reiki treatment twice a week;)

List any transformational workshops or seminars i.e., Silva Mind Method, The Forum, Avatar, Life Stream, etc. that you have participated in.

List any body work that you have received on a regular basis. (Reflexology, Polarity, Feldenkrais, Alexander Technique, etc.).

List any Masters, Gurus, Spiritual Guides, Channels, whose work has influenced you.

I understand and agree that any information I receive from Constance Barrett is not to be construed as directions, recommendations or prescriptions of any kind. Said information is not to be interpreted as a substitution for, or an addition to, medical advice, opinions, or treatment from a qualified physician. I agree to indemnify and hold Joyce Kaessinger and Constance Barrett harmless from any and all claims and from any and all loss, damage, liability or expense, including cost of suit and attorney's fees, resulting from or arising out of my use of said information for the above mentioned purposes.

Signature: Date

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Mail to: Beyond the Rainbow, PO Box 110, Ruby, NY 12475

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