N.O.W.S National Online Wellbeing Service

COMPLETE ONLY IF YOU ARE NOT ATTENDING A AROMATHERAPY APPOINTMENT - Disclaimer - (please click to confirm you have read this)

NOWs aromatherapy consultation is a sensory experience to support your individual needs and create a unique blend. By using a blend of essential oils and batch flowers, it can help to support your wellbeing through smell alone.

For younger children, the form is be filled out by the parent/carer asking the child/young person the relevant questions where necessary. Using your child's language (their words).

If your child is unsure how to answer the question, please complete the question yourself and make a note that these are your observations.

Please share as much information within the form for our clinical aromatherapist to tailor your unique blend.

Date

Todays date

Who is the aromatherapy blend for

Child (aged 4-12)

Young person (aged 13-18)

Parent / Caregiver

Full name

of person receiving aromatherapy tailored blend

D.O.B

of person receiving aromatherapy tailored blend

Parent/carer email address

Parent/carer full name

If completing for a child / young person receiving aromatherapy tailored blend

Home Address

Include your post code (and any delivery information required)

Additional information on how you want the aromatherpy to make you feel:

Please share as much information as possible that supports the Aromatherapist to tailor a unique blend.

For a child / young persons blend, please use your child's own words where possible.

Is there an area anywhere on your body that you feel these emotions?

Increased heart rate

Tight chest (feeling breathless)

Upset tummy (butterflies, feeling sick)

Headache

Pins and needles in the hands and feet

Other: (Please specify in additional notes below)

(I.e feeling sick, stomach ache, headache)

Additional notes:

Please share as much information as possible that supports the Aromatherapist to tailor a unique blend.

For a child / young persons blend, please use your child's own words where possible.

Energy Levels

Low (feeling tired and flat with no energy)

Full of energy (motivated, focused)

Mixture (sometimes low and sometimes energised)

How are your energy levels?

Which smells do you prefer?

Please select one (Fresh or Sweet)

Which smells do you prefer?

Please select one (Fruity or Citrus)

Which smells do you prefer?

Please select one (Warm or Cool)

Other smells you like

Other smells you dislike

If you could pick a colour to match your favoiurire smell, what colour would it be?

Medical Information

Please provide any medical information or contraindications that may effect the bespoke blend (including pregnancy, diagnosis, symptoms)

Medication

Please list any prescribed medication or natural remedies

Do you have any known allergies or sensitivities

Additional notes or any other relevant information:

Parent/carer consent

Yes

I consent for the aromatherapy blend to be made from the information that I have provided above and that the information I have provided is true to best of my knowledge and belief.

Clinical Aromatherapy