Mental-Emotional Survey

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 cheerfulnessI dislike arguments and give in to avoid conflictI turn to food, drugs, etc., when feeling down

ASPEN

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

BEECH

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

CENTAURY

I often neglect my own needs to please othersI find it difficult to say NOI tend to be easily influenced

CERATO

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

CHERRY PLUM

I’m afraid I might lose control of myselfI have sudden fits of rageI feel like I’m going crazy

CHESTNUT BUD

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

CHICORY

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

CLEMATIS

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

CRAB APPLE

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

ELM

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

GENTIAN

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

GORSE

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

HEATHER

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

HOLLY

I am suspicious of othersI feel discontented and unhappyI am full of envy, jealousy, mistrust, hate, vengefulness

HONEYSUCKLE

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

HORNBEAM

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

IMPATIENS

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

LARCH

I lack self-confidence and self-worthI feel inferior and often become discouragedI expect to fail / I expect failure

MIMULUS

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

MUSTARD

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

OAK

I tend to overwork and keep working in spite of exhaustionI have a strong sense of duty and never give upI neglect my own needs in order to complete a task

OLIVE

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

PINE

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

RED CHESTNUT

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

ROCK ROSE

I sometimes feel terror and panicI become helpless and frozen when afraidI suffer from nightmares

ROCK WATER

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

SCLERANTHUS

I find it difficult to make decisionsI often change my mind/opinionI cannot make up my mind

STAR OF BETHLEHEM

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

SWEET CHESTNUT

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

VERVAIN

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

VINE

I tend to take charge of projects, situations, etc.I tend to be domineering without regard for othersI 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 forwardI want to be free to follow my own ambitions

WATER VIOLET

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

WHITE CHESTNUT

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

WILD OAT

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

WILD ROSE

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

WILLOW

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

Mental-Emotional Survey

End of Survey !