Bach Flower Remedies Assessment & Consent Form

Bach Flower Remedies don't treat physical complaints directly but rather, work at creating a positive outlook within all negative emotions helping you gain control of your life and making you feel good about yourself through promotion of emotional wellness and empowerment. Name: Address: City: Province/State: Country: Postal/Zip Code: Home Phone: Cell Phone: Personal email address: Birth Date (dd/mm/yy): Gender:male female Are you?pregnant nursing Marital Status:single married divorced separated widowed Work phone: Emergency contact: Emergency telephone: Emergency cell phone: Describe any concerns and your objectives in seeking Bach Flower Remedies. PRESENT SITUATION: How am I reacting to my current problem? Please check ONLY ONE of the phrases from the list below which applies to what you are feeling right now. I am feeling guilty & am blaming myself. yes I am feeling uncertain, question my own judgment & follow the advice of others. yes I am feeling distrustful, emotionally hurt, hostile, angry, jealous or resentful. yes I am feeling as though I am not here & my mind is preoccupied with other things. yes I am feeling irritated because things are to disorderly, I feel dirty, nauseated or disgusted, I feel the need to clean up. yes I feel abandoned, as though fate has treated me unjustly. Poor me! yes I am feeling driven to impose my will to succeed. yes I am feeling tired, I do not have the energy & initiative to face a day’s work. yes I am feeling unstable and too easily swayed, I wish I could be true to myself. yes I am feeling melancholy, sad & depressed and I do not know why yes I am feeling inferior, as though I am a loser, less able than others, as though I am a second rate person. yes I am feeling like an exhausted fighter still on duty by myself, there is no way I will quit now. yes I am feeling afraid. I am scared of a certain situation or person. yes I am feeling to soft and to nice, I can never say no. yes I am feeling nostalgic, I just can't let go of a situation. yes I am feeling overwhelmed by my responsibilities, I can't go on any longer. yes I am feeling indifferent, I have given in to a situation. yes I am feeling undecided, scattered, dissatisfied, uncertain whether this is really what I want. yes I am feeling impatient, everything is moving to slowly. yes I feeling needy, I need affection & sympathy. yes I am feeling as though I have to grin & bear, I am pretending that things are alright. yes I am feeling reserved & want to withdraw and be left alone. yes I am feeling perplexed because I am making the same mistake. yes I am feeling bothered by unwanted thoughts & persistent inner dialogue, I just can't tune them out. yes I am feeling very enthusiastic – 150% committed. yes I am against a wall, I am desperate & have no idea how to go on from here. yes I am feeling as though I am still in shock, I have not digested it yet. yes I am feeling torn between two things, I am really out of balance. yes I am feeling drained, zapped & exhausted. yes I am feeling like an athlete in training, mercilessly denying myself everything. yes I am feeling defeated and without hope, I am resigned. yes I am feeling vaguely threatened, I can't handle my fears. yes I am feeling unloved, I feel hurt or disappointed because I expected more gratitude or appreciation for what I have done. yes I am feeling completely absorbed by my fears for someone else. I don 't even know what I feel myself. yes I am feeling discouraged, skeptical & despondent. yes I am feeling as if I am sitting on a powder keg ready to explode. I am barely able to control myself. yes {situation-thirty-seven title yes I am feeling panic stricken. I have lost my mind & my nerves are on edge. yes CHARACTER QUESTIONAIRE: What are the negative behavior patterns that keep me from implementing my goals? Please check ALL that apply. I hold myself back because I am timid & scared it will involve too much effort & stress. yes I hold myself back with my low esteem, I don't believe I can do it. yes I hold myself back for my strong need for harmony, I dislike ugly disputes & arguments. yes I hold myself back because I am completely exhausted & everything takes to much effort. yes I hold myself back by being to sensitive. When I think about changing this, I am taken over by strange feelings I cannot describe. yes I hold myself back with my constant criticism of others & myself. There are many things that disturb me but it is impossible for me to turn a blind eye. yes I hold myself back with my wish to please, I cannot say no. yes I hold myself back with my tendency to live in the past. I can't forget how it used to be. yes I hold myself back with my lack of inner drive. I always feel like it is Monday morning and I just can't get going. yes I hold myself back by fearing that I will lose control of myself. If I let go of my feelings, I don't know what I will become. yes I hold myself back by distrusting others & feeling jealous. I can easily become aggressive. yes I hold myself back with my lack of inner direction. It is difficult for me to know what I really want. yes I hold myself back by blaming myself for everything. If I make this change I know I will find things to be guilty of. yes I hold myself back because I am vulnerable. I am afraid of being hurt again as I was before. yes I hold myself back by not being able to stick to my decisions. First I prefer one solution & the next moment I prefer another. yes I hold myself back with my extreme sense of duty. I feel as though I always have to keep struggling on. yes I hold myself back by being so driven & enthusiastic. I always seem to overdo it & get on peoples' nerves. yes I hold myself back with my strong sense of fairness. I cannot see an unjust situation without having to do something about it. yes I hold myself back by doubting my judgment & always check with others just to make sure. yes I hold myself back because I tend to panic easily. I feel totally helpless just thinking about it. yes I hold myself back by being overly disciplined. I am always setting standards for myself that are too high. yes I hold myself back by being overly ambitious. I always want to have things done my own way. yes I hold myself back by being picky about details & cleanliness. When things are not right I get nervous. yes I hold myself back with my feelings of hopelessness. It is no use anymore. yes I hold myself back by being so absorbed in myself. I do not pick up on other peoples concerns. yes I hold myself back with my dreaminess. I seem to lack any interest in reality. yes I hold myself back with impatience & am unable to wait for things to happen. yes I hold myself back by being to sympathetic. I know exactly what the other person will feel & become overly concerned for him/her. yes I hold myself back with my melancholy disposition, at times it paralyzes me. yes I hold myself back with apathy, deep inside, I don't care about improving the situation. yes I hold myself back with a tendency to be aloof. I find it difficult to jump in & mingle with others. yes I hold myself back with a steady stream of chatter in my head. I am unable to concentrate on what is important. yes I hold myself back because I am to easily influenced. I let others interfere with my plans instead of staying true to myself. yes I hold myself back by not really paying attention. I tend to make the same mistakes over & over again. yes I hold myself back with my skepticism. I just do not expect things to end well. yes I hold myself back with my exaggerated sense of responsibility. It keeps me from putting on the brakes before I am overwhelmed. yes I hold myself back because I expect to much of others. I get involved & then expect recognition or gratitude in return. yes I hold myself back because I tend to let something go until there is no way I can do anything about it. yes I hold myself back with self pity. I am resentful & see myself as a victim of circumstance. yes FINAL CHECK LIST: What is most bothersome right now? Please check ONLY SIX . my anxiety yes my lack of self esteem or feelings of inferiority yes my need for harmony yes my lack of energy & enthusiasm yes my vague fears yes my intolerance yes my inability to say no yes my tendency to dwell in the past yes my mental weariness yes my inner emotional pressure yes my anger, jealousy & envy etc. yes my lack of inner direction yes my feelings of vulnerability, shock & numbness yes my tendency to blame myself for others mistakes yes my indecision yes my need to endure at any cost yes my excessive zeal yes my inner uncertainty yes my panic yes my exaggerated discipline yes my need to dominate yes my tendency to be picky about details & cleanliness yes my hopelessness yes my tendency to be too self absorbed yes my dreamy & unrealistic nature yes my impatience yes my tendency to be tied to someone emotionally yes my deep gloom yes my apathy yes my isolation or tendency to retreat yes my never ending thoughts yes my inability to be true to myself yes my tendency to repeat the same mistakes yes my negative expectations yes my tendency to be overly responsible yes my possessiveness or need to manipulate yes my despair & desperation yes my bitterness yes Were you referred by someone?yes no If yes, please give us their name & phone # so we may thank them: Bach Flower remedies Consent Waiver: I understand Jeni Shaw or the attending practitioner are not medical doctors nor do they portray themselves to be, but are providing Bach Flower Remedy services only. I fully understand that Bach Flower Remedies are utilized for relief of emotional stresses and imbalance. I understand that Jeni Shaw or the attending practitioner do not offer allopathic drugs, surgery, chemical stimulants or any other conventional medical treatments. In using Bach Flower Remedies, Jeni Shaw or the attending practitioner do not diagnose, treat, cure or otherwise prescribe for my disease, condition or illness. I have solicited Jeni Shaw’s or attending practitioner's services in good faith, exercising my free will and following the dictates of my own conscience, which allows me to select, what I understand, is most beneficial to my health at this present time. I am fully aware and release Jeni Shaw or the attending practitioner to utilize Bach Flower Remedies on me and that all information disclosed as well as my identity will be held in the strictest confidence except as specifically required by law. By including my name and checking "yes" to the "I consent" option below, I acknowledge that I have read and understand all parts of this waiver and that I have had the opportunity to ask questions with regard to the described programs. I hereby confirm I am not here for medical, diagnostic or treatment procedures and am here on this and any subsequent visits of my own free accord. I presently seek Bach Flower Remedies and or any other programs within the scope of Jeni Shaw or the attending pracrtitioner for Bach Flower Remedies. Name: Date (dd/mm/yy): I consent:yes no

 

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