Name * How did you hear about us?
e.g.. Google Search, Friend Referral, Yelp, etc.
* Gender * Female Male Date of Birth *
MM slash DD slash YYYY
Phone * Email *
Emergency Contact (first and last name, phone number) * Agrimony I hide my feelings behind a facade of cheerfulness iIdislike arguments and often give in to avoid conflict I turn to food, work, alcohol, drugs, etc when down None Aspen I feel anxious without knowing why I have a secret fear that something bad will happen I wake up feeling anxious None Beech I get annoyed by the habits of others I focus on others’ mistakes I am critical and intolerant None Centaury I often neglect my own needs to please I find it difficult to say “no” I tend to be easily influenced None Cerato I constantly second-guess myself I seek advice, mistrusting my own intuition I often change my mind out of confusion None Cherry Plum I’m afraid I might lose control of myself I have sudden fits of rage I feel like I’m going crazy None Chestnut Bud I make the same mistakes over and over I don’t learn from my experience I keep repeating the same patterns None Chicory I need to be needed and want my loved ones close I feel unloved and unappreciated by my family I easily feel slighted and hurt None Clematis I often feel spacey and absent minded I find myself unable to concentrate for long I get drowsy and sleep more than necessary None Crab Apple I am overly concerned with cleanliness I feel unclean or physically unattractive I tend to obsess over little things None Elm I feel overwhelmed by my responsibilities I don’t cope well under pressure I have temporarily lost my self-confidence None Gentian I become discouraged with small setbacks I am easily disheartened when faced with difficulties I am often skeptical and pessimistic None Gorse I feel hopeless, and can’t see a way out I lack faith that things could get better in my life I feel sullen and depressed None Heather I am obsessed with my own troubles I dislike being alone and I like to talk I usually bring conversations back to myself None Holly I am suspicious of others I feel discontented and unhappy I am full of jealousy, mistrust, or hate None Honeysuckle I’m often homesick for the “way it was” I think more about the past than the present I often think about what might have been None Hornbeam I often feel too tired to face the day ahead I feel mentally exhausted I tend to put things off None Impatiens I find it hard to wait for things I am impatient and irritable I prefer to work alone None Larch I lack self-confidence I feel inferior and often become discouraged I never expect anything but failure None Mimulus I am afraid of things such as spiders, illness, etc. I am shy, overly sensitive, and modest I get nervous and embarrassed None Mustard I get depressed without any reason I feel my moods swinging back and forth I get gloomy feelings that come and go None Oak I tend to overwork and keep on in spite of exhaustion I have a strong sense of duty and never give up I neglect my own needs in order to complete a task None Olive I feel completely exhausted, physically and/or mentally I am totally drained of all energy with no reserves left I’ve just been through a long period of illness or stress None Pine I feel unworthy and inferior I often feel guilty I blame myself for everything that goes wrong None Red Chestnut I’m overly concerned and worried about my loved ones I’m distressed and disturbed by other people’s problems I worry that harm may come to those I love None Rock Rose I sometimes feel terror and panic I become helpless and frozen when afraid I suffer from nightmares None Rock Water I set high standards for myself I am strict with my health, work and/or spiritual discipline I am very self-disciplined, always striving for perfection None Scleranthus I find it difficult to make decisions I often change my opinions I have intense mood swings None Star of Bethlehem I feel devastated due to a recent shock I am withdrawn due to traumatic events in my life I have never recovered from loss or fright None Sweet Chestnut I feel extreme mental or emotional heartache I have reached the limits of my endurance I am in complete despair, all hope gone None Vervain I get high-strung and very intense I try to convince others of my way of thinking I am sensitive to injustice, almost fanatical None Vine I tend to take charge of projects, situations, etc. I consider myself a natural leader I am strong-willed, ambitious and often bossy None Walnut I’m experiencing change in life–a move, new job, etc. I get drained by people or situations I want to be free to follow my own ambitions None Water Violet I give the impression that I’m aloof I prefer to be alone when overwhelmed I often don’t connect with people None White Chestnut I am constantly thinking unwanted thoughts I repeatedly relive unhappy events or arguments I’m unable to sleep at times because I can’t stop thinking None Wild Oat I can’t find my path in life I am drifting in life and lack direction I am ambitious but don’t know what to do None Willow I feel resentful and bitter I have difficulty forgiving and forgetting I think life is unfair and have a “Poor me attitude” None CAPTCHA