Practitioner Questionnaire
and Application for the
FES Referral Network

Please enter your name, address and contact information:

Title: (Dr,. etc.)
First Name:
Middle Name:
Last Name:
License: (DC, MD, etc.)
Organization:
Address:
City:
State/Province:
Postal Code:
Country:
Office Phone:
Home Phone:
Fax:
Email:
Web Site:

General Description of Practice:

Please identify your health or counseling practice(s) (chiropractor, psychiatrist, counselor, homeopath, massage practitioner etc.)
What are your areas of specialization?
Please comment further on the nature of your practice:
Is your practice full- or part-time?

Full-time
Part-time

Do you work alone or with other practitioners?

Work alone
Work with other practitioners

Do you offer consultations at a distance?

by telephone
by mail or email

Do you speak and work with clients in another language than English, and if so, what language is it?

Professional Information:
Describe your educational background and special training related to the health field:
What professional licenses and/or degrees do you hold?

Use of Flower Essences:
In what year did you begin your practice?
In what year did you begin using flower essences?
What ranges of flower essences do you use?

Flower essences of Dr. Bach
FES flowers
Healing Herbs
Other ranges:

Are you actively working with FES research essences?
How are essences used in your practice? Are they your primary tools in your practice, or are they mainly used to support other types of therapies? Primary tools
Use to support other therapies
What methods do you use to administer the essences? (dosage bottle, topical application, etc.)
How do you select essences?
Describe your record-keeping procedures:

Essential Oils:
Are you working with essential oils? Please describe how they are used in your practice:

Body Therapy Products:
Are you working with skin creams and/or oils? Please describe how the are used in your practice.

Follow-up and Research:
Do you do follow-up visits or calls with your clients to check their progress? Yes
No
Are you willing to share case histories for research and educational purposes? Yes
No
Are you willing to be interviewed on your use of flower essences? Yes
No
Tell us about any educational, research or other special projects you may be working on that involve flower essences.

Other Services:
Do you offer classes or other educational services? Yes
No
If so, please describe your educational programs.
Do you dispense flower essences in dosage bottles? Yes
No
Do you sell flower essences and other health products to your clients, and/or to the general public? Yes
No

Practitioner Referral Network
This is a service of the Flower Essence Society and requires membership in the Society.
For further information, click here.

Do you wish to be part of the Flower Essence Society Practitioner Referral Network? (You must also be a member of the Society in order to be listed.)

Yes
Not at this time

If yes, please indicate if you wish us to either delete your street address from the on-line listing,
or not include you in the on-line listing (in which case only our office will give out your information.

Omit my address in the on-line listing.

Omit my e-mail in the on-line listing.

Do not list me on-line

Please describe your fee rates and basis (e.g. flat fee or sliding scale).
Do you bill insurance? Yes
No
When are you available for consultations?
What are the best days of the week, times of day, and phone numbers to reach you?

Additional Information:
Please tell us anything additional about yourself and your practice which you think would be important for us to know. We are especially interested in hearing your insights about any particular flower essences or essential oils you are using.

In order to prevent automated attacks on our web site, we ask you to please input the text you see in the image below:
Validation

Please mail your business card, brochure, and/or catalogues,
or any news clippings or flyers which describe your practice.

We NEVER sell or trade any of our customers' personal information
with any other organization or company; and mailings, except for those requested, are rare.

 


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P.O. Box 459, Nevada City, CA  95959
800-736-9222 (US & Canada)
tel: 530-265-9163    fax: 530-265-0584

E-mail: mail@flowersociety.org

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