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Bach Flower Therapy Online

Bach Flower Therapy Assessment
(Child)

Please complete the following Bach Flower Therapy Online Assessment.

After you click on the submit button, you will be asked to provide the payment
of $45.00 USD through PayPal.

You can Pay directly from your PayPal balance or linked bank account. Or charge it to your credit card.

If you expereince any problems, please contact us.

Please note that all fields followed by an asterisk must be filled in.
First Name*
Last Name*
E-mail Address*
Street Address*
City*
State/Prov*
Zip/Postal Code*
Country*
Home Phone*
Parent First Name*
Parent Last Name*
Number of siblings to this child:*
Parent relationship to the child:*
Age of the child:*
Gender of the child:*
Describe the condition or situation which you would like to change with the help of Bach Flower Therapy (include as many details as possible):*
Describe what physical symptoms or conditions the child is experiencing:*
Describe how your child sleeps at night:*
Describe your child behaviour with the parents:*
Describe how the child deals with strangers, unknown situation and unfamiliar places:*
Describe how the child interacts with other children:
Only select the circumstance that apply to your child:
1. The child sleep too much.
2. The child is very fearful and often has separation anxiety.
3. The child gets easily and frequently offended.
4. The child demands constant attention.
5. The child high-strung or demanding and wants it all, now!
6. Thy child tries to hide his or her distress and put on a happy face.
7. The child has a fearful, shy, bashful temperament.
8. The child feels guilty or is afraid of disappointing the parents.
9. The child has trouble learning new things.
10. The child looks sad and depressed for no apparent reason.
11. The child gets easily homesick when away from home.
12. When playing or learning, the child gives up easily, or feels that it is not worth trying.
13. The child suffers from panic attack or extreme fear.
14. The child sleeps an excessive amount, yet complain of fatigue?
15. The child was born prematurely.
16. The child is smaller and weaker than his/her age.
17. The lacks confidence?
18. The child prefers to be alone, and prefers to play by himself even if other kids are around.
19. The child finds it difficult to deal with failure. If he/she makes a mistake they get upset easily.
20. The child is very restless and always on the go.
21. The child says “It’s not fair” all the time when asked to do something.
22. The child has mood swings and goes from one extreme to the next easily.
23. The child has a traumatic birth and has never been well since.
24. The child has a great fear of the dark, monsters, etc.
25. The child becomes over tired and gets very restless and it is hard to put to sleep.
26. The child displays attacks of jealousy often.
27. The child is overly concerned with being clean.
28. The child exhibits obsessive self destructive behaviour.
29. The child is unable to relax, has always something he needs to do better.
30. The child has experience a traumatic event or shock.
31. The child is constantly seeking attention and becomes very clingy.
32. The child has difficulty adjusting to change (new home, new sibling, potty training, school, new environment, etc.)
33. The child has difficulty breaking old habits.
34. The child is overly sleepy during the day
35. The child is often apathetic with lack of energy.
36. The child has frequent nightmares that give him/her a great state of panic and terror.
37. The child has hysterical or recurrent nightmares.
38. The child becomes very anxious about the wellbeing of others especially parents or siblings. 39. The child can be irritable and short-tempered.
40. The child gets annoyed easily when interacting with others or toys.
41. The child is easily excitable about new things and activities and it is hard to get him/her away from them.
42. The child becomes quite demanding when he/she wants something.
43. The child can be outgoing and happy but hide what is in his or her mind.
44. The child feels dominated (bullied) by others.
45. The child experiences small setback that make him sad and he does not want to try on.
46. The child is absent mind and has difficulty focussing and remembering.
47. The child often exhibits the "shrugged shoulder" approach with not enthusiasm about anything.
48. The child is often bullied by aggressive behaviour of others.
49. The child does not reveal an unpleasant events to the parents and keeps them to himself/herself.
50. The child has many fears.
51. The child appears fearful but when asked about it does not know why.
52. The child has difficulty learning form past mistakes.
53. The child always needs a parent or a friend with him and cannot do things alone.
54. The child is very imaginative, full of ideas and questions about the future.
55. The child is very undeceive and cannot make up his/her mind.
56. The child plays aggressively and wants to be the leader all the time.
57. The child is very tidy and gets upset is something happens to his/her things.
58. The child angers easily at other kids has temper tantrums with toys.
59. When upset, the child becomes overexcited, fixed and obsessed about it and very difficult to calm down.
60. The child is often intolerant of other kids inability to do something.
61. The child get temper tantrums that get out of control.
62. The child is easily discouraged and gives up hope and stops trying.
63. The child who goes to school gets overwhelmed by its responsibilities.
64. The child always has difficulty making a choice and cannot make up his/her mind.
65. The child tends to be constantly worrying and may lose sleep as a result.
66. The child gets physically exhausted easily, tired and fatigued
67. When working on a project or playing, the child wants to get it right and sinks into despair after repeated attempts.
68. The child need support and seeks constant reassurance.
69. The child is often aggressive with stubborn disobedience.
70. The child feels like everything that goes wrong is his/her fault.
71. The child often says: "I hate you!"
72. The child is often bitter and cannot forgive and forget.
73. The child reprimands and punishes himself and has very high standards.
74. The child lacks confident in his/her skills and abilities.
75. The child bravely stands up to adversities and does not let anything to get him/her down.
76. The child prefers to play alone and has an attitude that sets him/her apart from others (aloofness).
I understand that the information provided during this Bach Flower Therapy Assessment will be held in strict confidence. I further understand that the information I receive as a result of this Bach Flower Therapy Assessment is for educational purposes only. No information provided is intended to diagnose, treat or cure any disease or condition. Said information is not to be interpreted as a substitution for, or an addition to, medical advice, opinions, or treatment from a qualified physician. I agree to hold www.natural-health-for-fertility.com and its team harmless from any and all claims and from any and all loss, damage, liability or expense, including cost of suit and attorney's fees, resulting from or arising out of my use of said information for the above mentioned purposes. *
I Accept
Parent Name (Signature):*
Date (MM/DD/YYYY):*

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