Chakra Assessment

First Name

Last Name

Email Address

Please check any and all that apply to you:

I have chronic tension or pain in my shoulders and/or neck.

I have thyroid dysfunction/disease.

I want to discover/reclaim/empower my voice.

I want to feel that my life/work/relationships are a better reflection of my true/inner self.

I want to manifest what I DO want rather than what I don’t want.

I have something to say/do and I am having major difficulty saying it or doing it.

I want to spend more time and energy on my creativity/ creative projects/creative expressions..

I have a difficult time expressing my true thoughts and feelings around other people.

I want to be more thoughtful, truthful and powerful in my speaking/ living/ being.

At some point in my life something happened and I "lost my voice".

I am very uncomfortable with speaking in public/in front of others.

I have chronic tightness in my jaw/I get regular "tension headaches".

None of these apply to me

Please check any and all that apply to you (Part 2):

I have “issues” (discomfort/pain) in my bones, legs, knees, and/or feet.

I have “issues” with my adrenal glands/ suffer from adrenal fatigue.

I often feel unsafe, insecure, or “on the run” in some way.

I suffer from anxiety and feeling overwhelmed.

I feel like life is moving too quickly and you can’t seem to slow down.

I suffer from insomnia.

I suffer from chronic constipation.

I suffer from PTSD.

I have difficulty manifesting/ materializing my ideas.

I have a chronic lack of financial resources.

I have a sense of disconnect from my body/ the Earth/ other people and feel as if I am “hovering above” my life and my body.

I have trouble “letting go”.

None of these apply to me

Please check any and all that apply to you (Part 3):

I have a weak immune system/ I get sick often.

I suffer from tightness/tension/pain in my low back and hips.

I suffer from hormonal imbalance.

I often/easily feel overpowered by others.

I often/easily feel overwhelmed by my own emotions OR suppress my emotions so as to not feel them at all.

I have a desire for AND am afraid of intimacy.

I try to manipulate others to do what I want them to do.

I have difficulty staying balanced, both physically, mentally, and energetically.

I want to learn to "be myself" AND be with others at the same time.

I have chronic menstrual irregularity or physical dysfunction with my sex organs.

I want to be more creative/ have a creative outlet.

I want to experience more harmony and less conflict/ tension/ fighting.

None of these apply to me

Please check any and all that apply to you (Part 4):

I suffer from some type of endocrine dysfunction.

I want to improve my overall circulation. My extremities often and easily get cold.

I feel disconnected from Source/ Spirit/ God/ others.

I often/easily feel overpowered by others.

When I try to meditate I get frightened or overwhelmed or bored.

I suffer from chronic hormonal imbalance.

I am often discouraged/pessimistic.

I feel as if my life/my circumstances are stuck/determined and that there is little chance for change at this point.

I want to go more deeply and easily into meditative states.

I want to feel more connected to the life force/life source in myself and in others.

I want to feel more of a sense of freedom and possibility in my life/ in a specific circumstance.

I want to experience a sense of wholeness and peace.

I have a (sense of a) "glass ceiling" or limiting belief that is holding me back in some way.

None of these apply to me

Please check any and all that apply to you (Part 5):

I have digestive disorders.

I often feel “lost” or “confused” about my life’s work and purpose.

I often feel drained and lack energy and enthusiasm.

I suffer from being chronically overweight.

I lack confidence in myself.

I lack the focus and/or the energy to complete tasks.

I want to gain tools to boost and sustain my energy.

I often feel disrupted by intense feelings of anger and/or jealousy.

I crave/“need” sweets and caffeine to keep myself going.

I notice it takes quite a long time for me to process certain emotions or circumstances.

I am in the process of grieving.

I have diabetes.

None of these apply to me

Please check any and all that apply to you (Part 6):

I have a weak heart or irregular heart rhythm.

I have poor circulation.

I suffer from asthma or other respiratory ailments.

I want to increase my lung capacity and my ability to breathe deeply.

I suffer from an auto-immune disease.

I want to heal my heart and allow it to open again (and again).

I want to feel the balance of accepting/embracing myself and accepting/embracing others at the same time.

I give a lot to others and I want to get better at receiving from others.

I am having difficulty forgiving myself or another person for something.

I often feel the feelings/pain of others so much that it causes me pain and confusion.

I want to strengthen my heart and circulatory system

I want to develop a sense of connection and compassion for others whose lives and experiences are different than my own.

None of these apply to me

Please check any and all that apply to you (Part 7):

I suffer from migraines.

I want to improve my vision. My eyesight was never good/ is getting worse.

I have a hard time remembering things. I want to improve my memory.

I want to heal/restore a healthy relationship with my own intuition.

I want to connect more with the “awake time” dreams of my youth/my life. I have stopped dreaming.

I rarely remember my (sleeping) dreams.

I want to release any self-deceptions.

I want to learn to energize my pineal gland.

I desire to orient more "toward the Light".

I have experienced a traumatic brain injury at some point in my life.

I am seeking more clarity or insight about my life/ a particular circumstance/ a relationship.

I want to increase my ability to imagine/ visualize new scenarios for myself and my world.

None of these apply to me

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