Selacia's Flower Essence Remedy Form

Selacia’s Flower Essence Remedy Form

NOTE: Your information will never be shared with or sold to outside sources. See below for privacy statement.
ALL fields marked (*) are required before we can process.

First Name*

Last Name*

Date*

Email Address*

Have you used flower remedies before?*

What conditions were you seeking to address?*

Occupation/vocational interest or hobby:

What other therapies or significant growth experiences have you had?

Describe briefly your general state of health (e.g. low blood sugar, high blood pressure, chronic pain, headaches, allergies, PMS, menopause or any particular disease or out-of-balance physical condition).

Describe briefly your general mental state (e.g. thoughts of being inadequate or unable to fulfill what one desires, comparing oneself with others, worries about something specific, negative thinking about a particular area of life).

Describe briefly your general spiritual state (e.g. feeling disconnected from Source or spirit, doubtful of one’s intuitive abilities, or lacking courage or confidence to walk one’s spiritual path).

Describe briefly your feelings about work and other vocational interests (e.g. have difficulties focusing or concentrating, unable to connect with one’s creativity, overworked, feeling unappreciated, feeling overwhelmed by the amount of work that is required, conflicted about how to satisfy a very demanding supervisor, doubtful about ability to secure meaningful work, feeling underpaid or undervalued, lack of confidence about succeeding with work requirements).

Describe briefly your feelings in relation to major relationships (e.g. discord at home with children, arguments with partner, feeling lonely even when people are around, difficulties with intimacy, feeling unloved, disappointed by “love” or love relationships).

Select any of the following additional themes that can be addressed with this therapy:
lack of energy, stress, blocks to creativity, immune disturbances, eating disorders, depression, addiction, perfectionism, criticism, life direction, spontaneity, uncertainty, discouragement, anxiety, fear, lack of confidence, shyness, trauma, sleep disturbances, difficulty adjusting to new circumstances, separation anxiety, behavior problems, fear s, lack of desire/passion, overeating, anxiety that results in skin irritations or digestive upsets, emotional states or behaviors of pets, other (describe).

What is the chief condition you would like to resolve and how long have you had it?

If you would like to join Selacia’s opt-in Mailing List, please indicate your interests below. In the future, you will receive periodic emails specific to your interests. Many times, announcements are made only to Selacia’s email list, so this is the best way to be kept informed. You can choose, at any time, to unsubscribe, or to receive less or more information.

Selacia's Mailing List categories:
Books by Selacia
Channeling evenings
Crystals and crystal healing
DNA intuitive healing
Nonphysical world
Nutrition and rejuvenation
Pets
Teleclasses
Wesak celebrations

Comments:

REQUIRED FIELD:
For security purposes, before you Submit, please enter the code shown in the image below. It is recommended that you first print out this form so that you can have a copy for reference.

If you are a new client of Selacia’s (except for Pet Healing Sessions), please also fill out her New Client Form.
For pet healing sessions, please fill out her Pet Healing Form.

Privacy Statement
Privacy is important to us; therefore, we will not sell, rent, or give your name and address to anyone. You may choose, at any time, to unsubscribe from Selacia’s Mailing List.

© 2000-2007,
Communication for Transformation Group
All rights reserved.

First Name*
Last Name*
Date*
Email Address*
Have you used flower remedies before?*
What conditions were you seeking to address?*
Occupation/vocational interest or hobby:
What other therapies or significant growth experiences have you had?






Describe briefly your general state of health (e.g. low blood sugar, high blood pressure, chronic pain, headaches, allergies, PMS, menopause or any particular disease or out-of-balance physical condition).






Describe briefly your general mental state (e.g. thoughts of being inadequate or unable to fulfill what one desires, comparing oneself with others, worries about something specific, negative thinking about a particular area of life).






Describe briefly your general spiritual state (e.g. feeling disconnected from Source or spirit, doubtful of one’s intuitive abilities, or lacking courage or confidence to walk one’s spiritual path).
Describe briefly your feelings about work and other vocational interests (e.g. have difficulties focusing or concentrating, unable to connect with one’s creativity, overworked, feeling unappreciated, feeling overwhelmed by the amount of work that is required, conflicted about how to satisfy a very demanding supervisor, doubtful about ability to secure meaningful work, feeling underpaid or undervalued, lack of confidence about succeeding with work requirements).
Describe briefly your feelings in relation to major relationships (e.g. discord at home with children, arguments with partner, feeling lonely even when people are around, difficulties with intimacy, feeling unloved, disappointed by “love” or love relationships).
Select any of the following additional themes that can be addressed with this therapy: lack of energy, stress, blocks to creativity, immune disturbances, eating disorders, depression, addiction, perfectionism, criticism, life direction, spontaneity, uncertainty, discouragement, anxiety, fear, lack of confidence, shyness, trauma, sleep disturbances, difficulty adjusting to new circumstances, separation anxiety, behavior problems, fear s, lack of desire/passion, overeating, anxiety that results in skin irritations or digestive upsets, emotional states or behaviors of pets, other (describe).
What is the chief condition you would like to resolve and how long have you had it? If you would like to join Selacia’s opt-in Mailing List, please indicate your interests below. In the future, you will receive periodic emails specific to your interests. Many times, announcements are made only to Selacia’s email list, so this is the best way to be kept informed. You can choose, at any time, to unsubscribe, or to receive less or more information. Selacia's Mailing List categories: Books by Selacia Channeling evenings Crystals and crystal healing DNA intuitive healing Nonphysical world Nutrition and rejuvenation Pets Teleclasses Wesak celebrations Comments: REQUIRED FIELD: For security purposes, before you Submit, please enter the code shown in the image below. It is recommended that you first print out this form so that you can have a copy for reference.