Custom Essential Oil Blend Questionnaire
Ordering a custom essential oil blend is a simple, 4 step process.

1. First, complete the questionnaire and submit it to the Certified Aromatherapy Health Practitioner (CAHP).
2. You will then have a consultation with the CAHP to discuss your answers to the questionnaire. After the consultation, she will accept payment for your custom oil blend UNLESS YOU ARE A BETA CLIENT. Then the service is free of charge.
3. Next, the CAHP will send you the list of *potential ingredients* for your review. This is your opportunity to discuss the ingredient selection and share this list with your healthcare professional. You can request changes if needed.
4. Finally, the CAHP will craft your custom essential oil blend and mail it to you!

Email address *
Let's Get Started!
Allergies and Medical Concerns
Please provide the following information to help the CAHP craft your custom blend. These answers will address any contraindications to certain herbs.
Please note your food allergies. Give special thought to fruit and herbs: *
Required
Please note any current medical concerns:
Please list any medications and supplements that you are currently taking:
Please note any upcoming medical considerations, such as surgical procedures or if you plan to become pregnant:
What do you seek from custom essential oil blend #1?
The questions below will help the CAHP select ingredients for your blend.
Select 1 or 2 areas that you would like to address in blend #1? *
Required
Select 1 or 2 areas that you would like to address in blend #2 (if applicable)? *
Required
Essential Oil Profiles
The following questions will help the CAHP get an idea of your preferred aroma profiles.
How much do you like floral aromas?
Not at all
I love it!
Clear selection
How much do you like grassy or herbal aromas?
Not at all
I love it!
Clear selection
How much do you like woody aromas?
Not at all
I love it!
Clear selection
How much do you like fruity aromas?
Not at all
I love it!
Clear selection
How much do you like astringent aromas?
Not at all
I love it!
Clear selection
Currently, what are two of your favorite single essential oils?
What is your preferred carrier oil, if any?
Getting the Best Results
Good health is the practice of making many small decisions each day.Depending on the condition and the user, some blends have an immediate effect while others must be used consistently to see results. For example, a blend to promote relaxation may work immediately while a blend to encourage a healthy nervous system may take several weeks.
Do you understand that timelines for results may vary? *
Do you acknowledge that herbal remedies are a supplement to your wellness plan and not a substitute for the guidance of your trusted medical professional? *
You’re ready for your consultation!
Once you’ve completed the form, hit "Submit" to email it to the Certified Aromatherapy Health Practitioner. She will then be in contact with you to schedule the phone consultation.

If you have any questions, contact erica@deeplyrootedwellness.com.
A copy of your responses will be emailed to the address you provided.
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