Read each statement in each section then check all that apply to you.

In each section (of 3 statements) you can check all, none or any number of statements that apply to you.

If you are filling out the survey for a child, check all that apply to the child.

AGRIMONY

I hide my feelings behind a facade of cheerfulness I dislike arguments and give in to avoid conflict I turn to food, drugs, etc., when feeling down

ASPEN

I feel anxious (anxiety) without knowing why I have a secret fear that something bad will happen I wake up feeling anxious

BEECH

I get annoyed by the habits of others I focus on other’s mistakes I am critical and intolerant

CENTAURY

I often neglect my own needs to please others I find it difficult to say NO I tend to be easily influenced

CERATO

I constantly second guess myself I seek advice, mistrusting my own intuition I often change my mind out of confusion

CHERRY PLUM

I’m afraid I might lose control of myself I have sudden fits of rage I feel like I’m going crazy

CHESTNUT BUD

I make the same mistakes over and over I don’t learn from my experience I keep repeating the same patterns

CHICORY

I need to be needed and want loved ones close I feel unappreciated and unloved by my family I easily feel slighted and hurt

CLEMATIS

I often feel spacey and absent-minded I find myself unable to concentrate for long I get drowsy and sleep more than necessary

CRAB APPLE

I am overly concerned with cleanliness I feel unclean and/or physically unattractive I tend to obsess over little things

ELM

I feel overwhelmed by my responsibilities I don’t cope well under pressure I have temporarily lost my self-confidence

GENTIAN

I become discouraged by small setbacks I am easily disheartened in difficult situations I am often skeptical and/or pessimistic

GORSE

I feel hopeless and can’t see a way out I lost all faith that things can get any better I feel sullen and depressed

HEATHER

I am obsessed with my own troubles I dislike being alone and I like to talk I usually bring conversations back to myself

HOLLY

I am suspicious of others I feel discontented and unhappy I am full of envy, jealousy, mistrust, hate, vengefulness

HONEYSUCKLE

I am often homesick for the way it was I think more about the past than the present I often think what might have been

HORNBEAM

I often feel too tired to face the day I feel mentally exhausted and lack energy I tend to put things off (procrastination)

IMPATIENS

I find it hard to wait for things or people I am impatient and irritable I’d rather work alone to avoid time wasted, interference.

LARCH

I lack self-confidence and self-worth I feel inferior and often become discouraged I expect to fail / I expect failure

MIMULUS

I’m afraid of things like spiders, illness, death, etc. I am shy, overly sensitive and modest I get nervous and embarrassed

MUSTARD

I get depressed without any reason I feel my moods swinging back and forth I get gloomy feelings that come and go

OAK

I tend to overwork and keep working 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

OLIVE

I feel completely exhausted physically and mentally I am totally drained of energy with no reserves left I’ve just been through a long period of illness or stress

PINE

I often feel guilty I blame myself for everything that goes wrong I apologize for everything and say “I’m sorry”

RED CHESTNUT

I’m overly concerned & worried about my loved ones I worry obsessively about my health I’m a hypochondriac (irrational fear of disease)

ROCK ROSE

I sometimes feel terror and panic I become helpless and frozen when afraid I suffer from nightmares

ROCK WATER

I set high standards for myself and others I am strict with my health, work, family, etc. I am very self-disciplined, always striving for perfection

SCLERANTHUS

I find it difficult to make decisions I often change my mind/opinion I cannot make up my mind

STAR OF BETHLEHEM

I feel devastated due to recent or past shock/trauma I’m withdrawn due to traumatic events in my life I have never recovered from loss or fright

SWEET CHESTNUT

I feel extreme mental/emotional heartache I have reached the limits of my endurance I am in complete despair & all hope is gone

VERVAIN

I get high-strung and intense I persuade and try to convince others I am sensitive to injustice, almost fanatical

VINE

I tend to take charge of projects, situations, etc. I tend to be domineering without regard for others I am strong-willed, ambitious and bossy

WALNUT

I’m experiencing change in life: a move, new job, etc. I’m finding it difficult to move forward I want to be free to follow my own ambitions

WATER VIOLET

I give the impression that I am aloof, disinterested, distant I prefer to be alone when overwhelmed I often don’t/can’t connect with people

WHITE CHESTNUT

I’m constantly thinking and can’t stop thinking I repeatedly relive unhappy events or arguments I’m unable to sleep because I can’t stop thinking

WILD OAT

I can’t find my path in life I’m drifting in life and lack direction I’m ambitious but don’t know what to do

WILD ROSE

I’m apathetic and resigned to whatever happens I have the attitude “it doesn’t matter anyhow” I feel no joy in life

WILLOW

I feel resentful and bitter I have difficult forgiving and forgetting I feel life is unfair and have a “poor me” attitude

Mental-Emotional Survey

End of Survey !