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Energy Assessment
Please complete this assessment before our first session. Your answers to the questions below will help me determine your current energy status (what chakras are blocked, what mental/emotional energies we need to focus on, etc.).
Personal Info
Name *
Your answer
Email *
Your answer
Date of Birth *
Your answer
Exact Time of Birth (if known)
Time
:
Are you currently pregnant or nursing? *
Please list any serious illness or disease you are currently dealing with (i.e. clinical depression, heart disease/pace maker, seizures, cancer, etc.).
Your answer
What do you want to focus on for this energy healing session? (i.e. emotional distress, relationship issues, physical pain, etc.) Be as specific as you can. *
Your answer
Color Analysis
Color is an excellent diagnostic tool, which can get to the root of an emotional or physical problem, by tapping into the unconscious mind. Color analysis looks at the colors you like and dislike as these reveal messages coming from deep inside your psyche. This exploration uncovers inner feelings, desires and thought patterns.
Choose 3 colors: *
FIRST, CHOOSE THE 2 COLORS YOU ARE MOST ATTRACTED TO. FOR YOUR THIRD CHOICE, PICK A COLOR YOU DO NOT LIKE OR FAVOR LEAST.
Captionless Image
Red
Orange
Yellow
Green
Turquoise
Blue
Indigo
Violet
Magenta
First Choice
Second Choice
Third Choice
Root Chakra
Are you disorganized? *
Not at all
Extremely
Do you eat, drink or smoke excessively as a means of escape? *
Never
Always
Did you have some trauma, distress or difficulty between conception and the age of 7? *
How often do you feel anxious or fearful? *
Never
Always
Are you low in energy and often feel weak, tired or just not well? *
Do you have any physical problems in your legs, knees or feet? *
Do you often feel flighty, "unlike yourself" or disconnected from reality? *
Sacral Chakra
Do you have difficulty with touch – either being touched gently or being able to touch others? *
Do you suffer from asthma, allergies (such are skin conditions, candida, yeast infections, etc.)?or have problems with your kidneys or bladder? *
Did you suffer distress or trauma of any sort between the ages of 7 and 14? *
Do you feel that your general vitality & stamina are low? *
Do you have difficulties with any part of your sexuality? *
Do you feel your creativity is blocked or that you are not a creative person? *
Solar Plexus Chakra
Do you have digestive problems, e.g. ulcers, heartburn, blood sugar disorders or recurrent indigestion? *
Do you have an exceptional memory and learn new things quickly? *
Do you have an aggressive nature? *
Did you suffer distress or trauma between the ages of 14 and 21? *
How easily are you influenced by others? *
Not at all influenced by others
Very easily influenced by others
How often do you feel powerless or have a low self esteem? *
Never
All the time
Heart Chakra
Do you find it difficult to love or feel loved? *
Are you often intolerant, critical, or judgmental of others? *
Is your breathing deep and when stressful situations arise does your breathing pattern remain constant? *
Do you find it easy to forgive those who have mistreated you? *
Do you suffer from physical heart or lung conditions (i.e. pneumonia, heart disease, high blood pressure)? *
Throat Chakra
Do you often have ear, sore throats, shoulder or jaw tenseness or problems expressing yourself? *
Do you always communicate your inner truths and are you open and honest with others regardless of the situation? *
Are you shy, quiet, or withdrawn? *
Are you very organized and do you have a good ability to plan and give orders? *
Do you have a great fear of public speaking? *
Brow Chakra
Do you suffer from migraines, vision problems, nightmares, or insomnia? *
Do you have difficulty concentrating or visualizing concepts? *
Do you trust your "gut" instincts, intuition and insights? *
Do you feel like you are more intellectual, intelligent or mentally superior to others? *
Do you have a deep understanding of your existence that allows you to have little fear or anxiety about your future? *
Crown Chakra
Do you feel uncertain about your purpose or feel you lack a purpose? *
Do you consider yourself a visionary and is your creativity and inspiration unlimited? *
Do you feel separated from abundance, universal consciousness & wholeness? *
Do you have a fear of death and dying? *
Are you spiritually aware and are you in balance with your masculine and feminine energies? *
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