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Thank you for filling out this session request form. I will be back to you as soon as possible to arrange our meet-up.

Name

First Name

Last Name

Phone

(###)

###

####

Preferred Pronouns

She/Her

They/Them

He/Him

Birth Date

YYYY

Birth Time, Town, and State

When would you like to meet?

YYYY

Time

Hour

Minute

Second

Second Choice Date to meet

YYYY

Time

Hour

Minute

Second

Third Choice Date to meet

YYYY

Time

Hour

Minute

Second

What is (are) your goal(s) with working together? Please list 2-3 areas of your life that you would you like to focus on with me. Briefly describe the history of these issues including when they arose and how you have approached their healing.

What are your greatest sources of joy these days?

What are the sources of your greatest pain these days?

What major questions are you asking about your life at this time?

What do you see as your major points of growth these days?

Are you currently taking pharmaceutical medications? If so, what and for how long?

Have you worked with an herbalist before?

What herbal medicine have you worked with for this particular issue? Was it successful?

What medicinal herbs (if any) do not work for you?

Are you interested in working with flower essences?

Yes

Maybe - Tell me more

Are you pregnant or is there any possibility that you are?

Yes

Maybe

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