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
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, insomnia, 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 forget things often or have difficulty learning new concepts? *
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? *
Does your breathing pattern change or become erratic when you are confronted with stressful situations? Do you often have to tell yourself to "just breathe"? *
Do you find it difficult to forgive those who have mistreated you? *
Do you suffer from physical heart or lung conditions (i.e. pneumonia, heart disease, high blood pressure, asthma)? *
Throat Chakra
Do you often have ear, sore throats, shoulder or jaw tenseness or problems expressing yourself? *
Do you have difficulty being honest with others or expressing you truths & emotions? *
Are you shy, quiet, or withdrawn? *
Is it difficult for you to delegate or 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 have a hard time trusting your "gut" instincts, first thoughts, intuition and/or insights? *
Do you feel like you are more intellectual, intelligent or mentally superior to others? *
Do you question your existence or have fear or uncertainty about the future? *
Crown Chakra
Do you feel uncertain about your purpose or feel you lack a purpose? *
Do you feel like your inspiration & creativity is limited or blocked? *
Do you feel separated from abundance, universal consciousness & wholeness? *
Do you have a fear of death and dying? *
Is it difficult for you to feel balanced in both your masculine & feminine energies? *
Consent Agreement
I understand that Crystal Light Therapy or Reiki Energy work is not a substitute for medical treatment or psychotherapy. Your practitioner, Alexis J Alvarez, CCH, LPC, RMT, and Modrn Sanctuary do not practice medicine or psychotherapy and our services are not a replacement for counseling, psychotherapy, psychiatric or medical treatment. Our service provided is not proven or intended to diagnose, cure or treat any disease or illness, psychological or mental health condition. For more information about your practitioner's credentials, please visit: http://www.modrnsanctuary.com/alexis

I understand that Crystal Light Bed therapy is NOT appropriate for persons who are pregnant (unless ok'd by their physician) or have a pacemaker. I agree to the salt room terms & conditions (applies to salt room sessions only).

I understand that arriving late to my appointment will not change the allocated time of the appointment. I also agree to the current cancellation policy regarding Sensory 7 Luxury Experience sessions, as issued by Modrn Sanctuary or the current cancellation policy in place by Alektrik Crystals.

I confirm that I am 18 years of age or older.

I have read the above consent and I agree to the terms & conditions listed. (initials below) *
Your answer
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