Name *

First Name

Last Name

Contact Number *

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Agrimony 1 *

Does it seem that you are wearing a social mask, appearing carefree and cheerful to others, when deep inside you feel quite tormented?

Always

Sometimes

Never

Agrimony 2 *

Were you taught to deny your real feelings, to keep a "stiff upper lip," or maintain a veneer of social politeness?

Always

Sometimes

Never

Agrimony 3 *

Do you often rely on alcohol or other drugs to keep back any unpleasant or troubling emotions emotions, or to help you to feel at ease?

Always

Sometimes

Never

Aspen 1 *

Do you often find yourself anxious or fearful, or experience vaguely troubling nightmares, yet are at a loss to understand what is causing or prompting these feelings?

Always

Sometimes

Never

Aspen 2 *

Do you seem to have pronounced psychic sensitivity, easily registering impressions from unseen or unknown sources?

Always

Sometimes

Never

Aspen 3

Do you need to bring more spiritual strength and confidence to your daily life, transforming fear and anxiety to more wakeful perception and inner knowing?

Always

Sometimes

Never

Beech 1 *

Do you set high standards for others, making it almost impossible for them to live up to your ideals?

Always

Sometimes

Never

Beech 2 *

Does is seem that you are frequently in a position of criticizing or judging the behavior or performance of others?

Always

Sometimes

Never

Beech 3 *

Are you hypersensitive to the physical and social environment around you, needing to be surrounded by a "bubble" of perfection?

Always

Sometimes

Never

Centaury 1 *

Are you someone who finds it easy to serve others, but submerges your own identity or integrity in the process?

Always

Sometimes

Never

Centaury 2 *

Is it difficult for you to be in touch with your own needs for rest, play or creative expression; and do you find that you all too easily compromise these needs to meet the demands of others

Always

Sometimes

Never

Centaury 3

Do you feel that your will is weak, especially with regard to your own personal goals for inner development or self-realization?

Always

Sometimes

Never

Cerato 1 *

Do you doubt your own intuitive assessment of people or situations, frequently relying on the counsel of others?

Always

Sometimes

Never

Cerato 2 *

Do you commonly find yourself regretting choices you have made, realizing you were not in touch with your own inner wisdom at the time of the decision?

Always

Sometimes

Never

Cerato 3 *

Are you currently required to make life choices of critical decisions which require your utmost ability to form independent judgement and your own authentic evaluation?

Always

Sometimes

Never

Cherry Plum 1 *

Is your current life characterized by a great deal of pressure or stress, resulting in enormous feelings of emotional or physical tension?

Always

Sometimes

Never

Cherry Plum 2 *

Do you tend to cope with stressful or challenging situations by holding on all the tighter, as though letting go would mean that you had lost control?

Always

Sometimes

Never

Cherry Plum 3 *

Have you experienced moments of temporary insanity, or suicidal or destructive impulses, which make it hard for you to trust surrendering to your own natural impulses or inner sense of spirituality?

Always

Sometimes

Never

Chestnut Bud 1 *

Does it feel that you are somehow stymied or stuck, unable to make progress, repeating the same mistakes again and again in relationships and other life situations?

Always

Sometimes

Never

Chestnut Bud 2 *

Is it hard for you to step aside and observe your life, so that you can understand and learn from your experiences?

Always

Sometimes

Never

Chestnut Bud 3 *

Does it seem that you are a slower learner, needing to develop more ability to observe and discriminate in the life situations which you encounter?

Always

Sometimes

Never

Chicory 1 *

Do you often experience feelings of frustration, suspecting that others do not really appreciate your efforts?

Always

Sometimes

Never

Chicory 2 *

Do you find yourself wanting attention from others, especially the desire to have others acknowledge how much you are giving or ding for them?

Always

Sometimes

Never

Chicory 3 *

Are you possessive in relationships, wanting others to recognize how important you are in their lives?

Always

Sometimes

Never

Chicory 4 *

Do you find that many of your actions provoke the negative attention of others?

Always

Sometimes

Never

Clematis 1 *

Are you someone who lives more readily and comfortably in your own inner world, rather than in an outer world of daily affairs and responsibility?

Always

Sometimes

Never

Clematis 2 *

Do you have a highly developed imagination or psychic life, but find it difficult to focus or concentrate in the classroom or workplace?

Always

Sometimes

Never

Clematis 3 *

Are you attracted to drugs or other psychic experiences which give you a sense of expansiveness, and ease your feeling of constriction on the physical body of physical world?

Always

Sometimes

Never

Crab Apple 1 *

Are you often obsessed with feeling of imperfection, focusing on even the tiniest details which seem out of harmony?

Always

Sometimes

Never

Crab Apple 2 *

Do you feel unclean,impure or otherwise ashamed of your bodily functions or physical attributes?

Always

Sometimes

Never

Crab Apple 3 *

Are you often drawn to purification or cleansing rituals for your physical body or environment out of proportion to the real need?

Always

Sometimes

Never

Elm 1 *

Do you readily assume major tasks or responsibilities, only to find yourself completely overwhelmed or otherwise dysfunctional?

Always

Sometimes

Never

Elm 2 *

Are you someone who is frequently overly-responsible or over concerned in family or work situations, to the point of isolating yourself as the lone hero or rescuer?

Always

Sometimes

Never

Elm 3 *

Are you currently experiencing a great deal of fatigue, or even despondency, regarding a task or project for which you have assumed responsibility?

Always

Sometimes

Never

Gentian 1 *

Are you generally skeptical, often dwelling more on the problems than the solutions?

Always

Sometimes

Never

Gentian 2 *

Are you often discouraged by setbacks, viewing them as stumbling blocks rather than as learning lessons

Always

Sometimes

Never

Gentian 3 *

Do you easily succumb to doubt or pessimism, finding it hard to tackle any difficulty you experience with renewed forces or a fresh start?

Always

Sometimes

Never

Gorse 1 *

Does it seem that there is little hope for the challenging condition or situation you are now experiencing

Always

Sometimes

Never

Gorse 2 *

Does you personal world feel dark or menacing, with the feeling that you can expect no improvement or better of your situation?

Always

Sometimes

Never

Gorse 3 *

Have you lost faith or trust in your inner process of healing or transformation, believing that there is little you can do to improve your condition?

Always

Sometimes

Never

Heather 1 *

Does it seem that you are often absorbed in your life traumas or worries, needing to tell others about them, or wanting attention or consolation from others?

Always

Sometimes

Never

Heather 2 *

Is it challenging for you to be alone or to resolve problems independently, instead requiring a great deal of support from others?

Always

Sometimes

Never

Heather 3 *

Do you feel an intense inner loneliness or sense of insecurity, looking to others to help fill the emptiness you feel inside?

Always

Sometimes

Never

Holly 1 *

Are you plagued by feeling of jealously, rivalry, suspicious or vengefulness?

Always

Sometimes

Never

Holly 2 *

is it hard for you to feel compassion for the plight of others?

Always

Sometimes

Never

Holly 3 *

Do your feelings for others often turn to alienation, mistrust, or hostility?

Always

Sometimes

Never

Holly 4 *

Do you struggle or compete in order to receive love or recognition. feeling that others will get what is rightfully yours

Always

Sometimes

Never

Honeysuckle 1 *

Do you find yourself frequently dwelling on, or otherwise longing for a former relationship or living situation?

Always

Sometimes

Never

Honeysuckle 2 *

Does it seem that there was an earlier part of your life which was more glamorous or fulfilling than your current situation?

Always

Sometimes

Never

Honeysuckle 3 *

Do you find yourself wistfully nostalgic or romantic, convinced that life would be different if only you lived in another era or in a different circumstance?

Always

Sometimes

Never

Hornbeam 1 *

Do you feel fatigued or drained in your job, or in a work-project at home or school, out proportion to the real physical energy demanded for the task?

Always

Sometimes

Never

Hornbeam 2 *

Does life often seem like a monotonous routine, as though you are just going through the motions at work or home, with little interest or energetic involvement ?

Always

Sometimes

Never

Hornbean 3 *

Do you feel you need to develop a fresh perspective on your daily tasks and responsibilities, perhaps recapturing your original zest, or finding new and enlivening situation at work,home or school?

Always

Sometimes

Never

Impatiens 1 *

Do you often find yourself tense, irritable, or easily impatient and argumentative?

Always

Sometimes

Never

Impatiens 2 *

Do you tend to take over for others, finishing their sentences or completing their tasks because you know you can do it more quickly?

Always

Sometimes

Never

Impatiens 3 *

Does is seem that you are always rushing ahead of your experience, not really able to enjoy or pay attention to what is unfolding around you?

Always

Sometimes

Never

Larch 1 *

Are you your own worst critic, censoring, down-playing or otherwise stifling your creative expression or contribution?

Always

Sometimes

Never

Larch 2 *

Do you suffer from self-doubt, often lacking the essential confidence to take risks or be spontaneous?

Always

Sometimes

Never

Larch 3 *

Does your own fear of failure or expectation of criticism from others hold you back from making a unique or creative contribution in your work, community or social group?

Always

Sometimes

Never

Larch 4 *

Do you experience difficulty in speaking or performing publicly, adversely affecting your speech or presentation, even when you are sufficiently prepared?

Always

Sometimes

Never

Mimulus *

Do you find that you frequently shortchange yourself form a full experience of life, isolating yourself due to nagging fears or worries?

Always

Sometimes

Never

Mimulus 2 *

It is hard for you to be truly spontaneous or joyfully curious about life, paralyzed instead by annoying doubts, fears or worries?

Always

Sometimes

Never

Mimulus 3 *

Would you describe yourself as hypersensitive, frequently troubled or uneasy even when encountering ordinary or daily activities?

Always

Sometimes

Never

Mustard 1 *

Are you often subject to unexpected bouts depression or inner darkness?

Always

Sometimes

Never

Mustard 2 *

Does it seem that you readily experience mood swings, at times happy or joyful, then suddenly filled with feelings of gloom melancholy?

Always

Sometimes

Never

Mustard 3 *

Is it difficult for you to grasp the causes of your depression or anxiety, as though it comes from outside you like a dark cloud?

Always

Sometimes

Never

Oak 1 *

Are you hard-working and dependable, often pressing to the limits of endurance in order to provide for or assist others?

Always

Sometimes

Never

Oak 2 *

Do you feel you are on the verge of collapse or utter exhaustion due to the unrelenting pace you have set for yourself?

Always

Sometimes

Never

Oak 3 *

Do you over-strive beyond your true limits for capacities, generally denying yourself small pleasures or spontaneous moments of joy?

Always

Sometimes

Never

Olive 1 *

Are you facing now, or have you just completed an extremely challenging ordeal which requires you to muster all your physical stamina and resolve?

Always

Sometimes

Never

Olive 2 *

Do you feel that you have "spent" all of your physical energy, resulting in a profound sense of exhaustion and fatigue?

Always

Sometimes

Never

Olive 3 *

Do you generally seek physical measures to heal yourself, yet sense that your current exhaustion or dysfunction is so immune you must look elsewhere for complete recovery?

Always

Sometimes

Never

Pine 1 *

Did you grow up in a religious, social, or family situation which imparted a great deal of guilt or shame about your own self-worth?

Always

Sometimes

Never

Pine 2 *

Do you have unusually harsh expectations for yourself,readily resorting to self-blame if your performance is less than perfect?

Always

Sometimes

Never

Pine 3 *

is it hard for your to let go of past mistakes or failures, frequently dwelling on these rather than moving forward to new opportunities or risks?

Always

Sometimes

Never

Red Chestnut *

Do you frequently find yourself worrying or concerned about others' welfare, so much so that you are living more in their lives than your own?

Always

Sometimes

Never

Red Chestnut *

Is it hard for you to trust in the unfolding of life events for your children or other family for friends close to you?

Always

Sometimes

Never

Red Chestnut *

Are you needing to develop more detachment about a current relationship or social situation which is troubling you?

Always

Sometimes

Never

Rock Rose *

Do you frequently suffer from nightmares, or other experiences which bring a sense of terror or deep emotional disturbance?

Always

Sometimes

Never

Rock Rose 2 *

Are you currently facing a situation which has life-threatening or destructive proportions, such as an impending death or catastrophic emergency?

Always

Sometimes

Never

Rock Rose 3 *

Do you need to develop greater courage and equanimity in stressful situations?

Always

Sometimes

Never

Rock Water 1 *

Do you tend toward an ascetic or highly regimented style of living and eating?

Always

Sometimes

Never

Rock Water 2 *

Do you have strong religious, work, or study disciplines, which you follow relentlessly, or rigidly?

Always

Sometimes

Never

Rock Water 3 *

Do you feel that you deny yourself the opportunity to enjoy life on its own terms, generally subjecting yourself to strict schedules or external programs which allow for little spontaneity or creativity?

Always

Sometimes

Never

Scleranthus *

Do you frequently find yourself in situations where you seem torn between one or more options, unable to take a firm hold of your decision?

Always

Sometimes

Never

Scleranthus 2 *

Are you someone who often goes back and forth between people or situations, vacillating in your commitment or intentions?

Always

Sometimes

Never

Scleranthus 3 *

Do you experience a constant shifting of emotional states as well as physical symptoms, characterized by a great deal of restlessness or confusion?

Always

Sometimes

Never

Star of Bethlehem *

Were you subject to a very deep trauma or assault for which you feel you have never regained your original vitality or strength?

Always

Sometimes

Never

Star of Bethlehem 2 *

Does it seem that a deep sense of inner peace and self-containment is lacking in your life, due to stress and other trauma?

Always

Sometimes

Never

Star of Bethlehem 3 *

Have you suffered from a prolonged state of psychic stress which has led you to feel cut off from your Spiritual Self or deepest soul feeling

Always

Sometimes

Never

Sweet Chestnut *

Do you feel that you have hit "rock bottom" caught in such an extreme state of despair that there appears to be no way out?

Always

Sometimes

Never

Sweet Chestnut 2 *

Do you feel extreme mental anguish or suffering, as though you have reached the breaking point of what you can endure?

Always

Sometimes

Never

Sweet Chestnut 3 *

Are you experiencing a sense of utter aloneness or abandonment,testing your faith that there really is a Higher Power or loving spiritual source for you?

Always

Sometimes

Never

Vervain 1 *

Do you believe that the world would be better off it only others headed your vision and values?

Always

Sometimes

Never

Vervain 2 *

Do you possess great feelings of enthusiasm and intensity, so much so that you can tense and push your body beyond its natural energy level?

Always

Sometimes

Never

Vervain 3 *

Do you overwhelm others with your convictions, making it difficult for them to freely develop a response or openly explore your point of view?

Always

Sometimes

Never

Vine 1 *

Do you often demand obedience or allegiance from others, with a strong need to be in control or to direct others?

Always

Sometimes

Never

Vine 2 *

Are you frequently assertive to the point of being aggressive, wanting to be in charge and insure things will be done "your way"?

Always

Sometimes

Never

Vine 3 *

Do you possess such a strong will that it often seems to overpower or overwhelm those around you?

Always

Sometimes

Never

Walnut 1 *

Do you tend to be negatively influenced by family ties or social expectations which hold you back from following your own sense of conviction or destiny?

Always

Sometimes

Never

Walnut 2 *

Are you attempting to establish a new program of inner development, or change in lifestyle; yet finding yourself succumbing to old habit patterns, thoughts, or beliefs which retard your progress?

Always

Sometimes

Never

Walnut 3 *

Are you in a major state of transition - either physical or psychologist - which will require you to view yourself and others in an utterly new or courageous way?

Always

Sometimes

Never

Water Violet 2 *

Do you find yourself measuring others according to social status or economic background, often with the sense that you would not want to associate with someone beneath your level?

Always

Sometimes

Never

Water Violet 1 *

Does it seem that you are often rather aloof or socially distant, making it hard for people to really get to know you?

Always

Sometimes

Never

Water Violet 3 *

Are you at your best when you work independently, finding that when you work with others you are easily annoyed or otherwise stymied?

Always

Sometimes

Never

White Chestnut 1 *

Does your mind sometimes seem like a echo chamber, constantly replaying bits of conversations or life episodes without any apparent resolution?

Always

Sometimes

Never

White Chestnut 2 *

Do you suffer from a great deal of mental agitation or racing thoughts, often resulting in insomnia, fitful sleep, or general restlessness?

Always

Sometimes

Never

White Chestnut 3 *

Is it usually difficult for you to pray or meditate, or to experience as inner state of calm objectivity or inner peace?

Always

Sometimes

Never

Wild Oat 2 *

Do you have many talents and capabilities, yet find it difficult to really focus or harness these gifts towards a worldly vocation?

Always

Sometimes

Never

Wild Oat 1 *

Do you feel that your current vocation or lifestyle is not in keeping with your sense of inner destiny and life purpose?

Always

Sometimes

Never

Wild Oat 3 *

Are you chronically dissatisfied with your work or employment, unable to feel real commitment or interest even after trying many different situations?

Always

Sometimes

Never

Wild Rose 1 *

Has a prolonged illness or other life situation drained your of vitality or enthusiasm for life?

Always

Sometimes

Never

Wild Rose 2 *

Do you frequently feel resigned or apathetic, as though life seems hardly worth the effort it requires?

Always

Sometimes

Never

Wild Rose 3 *

Do you tend to recover from illness or other setbacks very slowly, seemingly unable to hardness the full forces of physical vitality which you need for recovery?

Always

Sometimes

Never

Willow 1 *

Do you tend to hold on to past injustices or misfortunes. leading to feelings of bitterness or resentment?

Always

Sometimes

Never

Willow 2 *

Do you frequently find yourself in the role of "victim," feeling that you are being persecuted or unfairly punished?

Always

Sometimes

Never

Willow 3 *

Are you emotionally inflexible, finding it difficult to forgive others, or to be accepting and yielding?

Always

Sometimes

Never