Title: (Dr., Rev., Mr., Ms., etc)
First Name: Middle:
Last Name: License: (MD, DC, PhD, etc.)
Organization or Company:
Address:
Address 2:
City State/Province: Zip/Postal Code:
Country: Native language:
Telephone: Fax: E-mail:

How many years have you been using flower essences? Comments:
List flower essence training and certification (year, location, organization):

What is your profession / practice:
List professional licenses / certifications / trainings:


1. How many patients with a depression element do you typically treat in a 6-month period of time?
Comments:

2. Depression has many faces. Sometimes it is the main issue.
Sometimes it occurs as an underlying or "attendant" symptom in combination with another main "theme."

3. Do you currently use any standardized psychological test to assess depression in you patients?
(for example, the Beck questionnaire, the Zung Depressions Scale, the Hamilton Depression Scale, CES-D)
Yes No
a. If yes, which instrument(s) do you use?
b. If no, would you be willing to use a brief (10 minute) depression screening tool as part of a
systematic study on the effects of Flower Essence therapy on depression? Yes No

4. Considering all the depressed patients you have seen, please indicate the five (5) most common presentations listed below. If we have left out any you see a lot, please use the "other" category. Please rank your selections in order of frequency by numbering them from 1 to 5, with 1 being the presentation you most frequently see.

012345 Depression associated with a keynote of alienation
012345 Depression with a keynote of hopelessness
012345 Depression with a keynote of physical exhaustion
012345 Depression with a keynote of sadness
012345 Depression with a keynote of self criticalness
012345 Depression with a keynote of agitation
012345 Depression with a keynote of mood swings
012345 Depression with a keynote of grief
012345 Depression with a keynote of disturbed sleep
012345 Depression with a keynote of strong suicidal tendencies
012345 Depression with a keynote of anger
012345 Depression with a keynote of anxiety
012345 Depression with a keynote of loss of personal relationship
012345 Other ( please specify)
012345 Other ( please specify)

5. When you treat a patient, it is most common to treat the whole person and
not just the symptom. However, sometimes there are patients who come to you for
whom you primarily treat just the symptom of depression. In what percent of
your patients might this happen? % of the patients I see.


6. When you treat a case where depression is a primary element
a. How many times do you typically see the patient?
b. How many weeks, months or years do you typically treat a patient with depression? weeksmonthsyears
c. How often do you see them?
Only once Once a week Once a month Once a quarter
d. How long is a therapeutic session? -hours, or -minutes
e. Once treatment is initiated, how many days / weeks / months is it before
you typically start seeing clinical results? daysweeksmonths
Comments:

7. Do you use a wide variety of essences for depression cases, or is there a
smaller subset of essences which you predominantly use? Please rate your use
pattern on the following 10 point scale.

8. Do you commonly combine multiple essences in your treatment of patients? Yes No

a) If yes, how many flower essences might you typically combine
into one bottle as you begin the treatment of depressed patient?
Comments:
b) Do you combine other kinds of remedies with flower essences
in the same bottle? Yes No

9. During the course of treatment, do you generally stay with the same
flower essence formula, or change / adjust the combination?
Stay with same combination Change the formula
a) If you change the formula, how long do your patients generally stay with a particular formula?
daysweeksmonths Comments:

b) During the course of treatment, how many different
flower essence combinations might you typically use with a patient?
Comments:

10. In her book Flowers That Heal, Patricia Kaminski has described four stages of transformation which are possible with flower essence therapy. (Click here for a summary.). Please give us a sense of how you see your use of flower essences for depression in the light of these four stages. Which stages are most commonly experienced; which more rarely; which not at all? What are typical time sequences for moving through these stages? Are there particular essences which are characteristic for depressed patients at particular stages. Please make your comments below:

a) Release and Relaxation:


b) Realization and Recognition:



c) Reaction, resistance and reconciliation:


d) Renewal and reconstellation:

11. What other natural remedies or therapies do you use? Check as many as apply
herbal remedies homeopathy vibrational remedies(gem elixirs, etc)
nutritional counseling acupuncture movement therapies
Ayurveda energetic touch massage other therapeutic body work
music artistic therapy Bioenergetics Biofeedback
psychotherapy / counseling
Other (please describe):
Other (please describe)
Other (please describe):

12. What self-awareness techniques do your patients employ?
symptom monitoring journaling
dream work artistic expression
others:

13. Do you prescribe anti-depressants or other pharmaceuticals? Yes No

14. If patients come to you who are taking anti-depressants, what do you typically do?
decline to work with them work with them without dealing with the drugs
try to "taper them of" the drugs consult with the prescribing physician
Other (please describe):
a If "tapering off" is attempted, are you generally successful? Yes No
b. If you have experience in this area, please comment about the relationship
between anti-depressants and flower essences in the treatment of depression.

15. Would you be willing to participate in this clinical trial? Participation involves obtaining consent from your patient to collect data and share this information with FES on a confidential basis. Practitioners will administer a standardized depression assessment tool periodically during your therapy, and document their cases using some simple forms provided by FES. A few sites will be chosen for a more extensive double-blind placebo study.

Yes, I am interested in participating in the FES Depression Study.
I may be interested in participating in the double-blind study. Please send more information.
No, I do not wish to participate at this time.

16. Are you interested in working with FES in the design of the study? Yes No If so, please describe your experience with clinical research:

17. Further comments:

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