Question 1 of 15

What is your first name? *

Question 2 of 15

What is your date of birth? *

Question 3 of 15

How safe and grounded do you feel in daily life? (Root Chakra) (1-10) *

Question 4 of 15

How freely do you express creativity and pleasure? (Sacral Chakra) (1-10) *

Question 5 of 15

How much do you trust your personal power and confidence? (Solar Plexus) (1-10) *

Question 6 of 15

How open is your heart to love and compassion? (Heart Chakra) (1-10) *

Question 7 of 15

How freely do you express your truth? (Throat Chakra) (1-10) *

Question 8 of 15

How strong and trusted is your intuition? (Third Eye) (1-10) *

Question 9 of 15

How connected do you feel to the divine? (Crown Chakra) (1-10) *

Question 10 of 15

Do you experience regular physical discomfort in any area? *

Lower back / hips Abdomen Chest Throat Chakra Head No regular pain Multiple practices

Question 11 of 15

Which emotional patterns do you notice in yourself? *

Select all that apply

Anxiety Anger Sadness Numbness Overwhelm Disconnection Fear No particular affinity

Question 12 of 15

What area of life drains your energy most? *

Work / Career Relationships Family Finances Health Self-expression Spirituality

Question 13 of 15

Have you tried any energy healing practices? *

Reiki Meditation Yoga Crystal work No particular affinity Multiple practices

Question 14 of 15

Which chakra do you feel is your strongest? *

Root Chakra Sacral Chakra Solar Plexus Chakra Heart Chakra Throat Chakra Third Eye Chakra Crown Chakra I don't know

Question 15 of 15

What is your intention for healing? *

Final Step

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