form – Chakra

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Before we get started, what is your name?

Name(Required)

QUESTION 1

ARE YOU IN ANY physical or mental pain?

are you In any Physical or Mental Pain?(Required)

Yes, mental pain

Yes, physical pain

Yes, both

No pain

QUESTION 2

Where is the Mental Pain?

Please select all that apply.

Where is the Mental Pain?(Required)

Anxiety or insecurity

Emotional instability or intimacy issues

Low self-esteem or lack of motivation

Struggle to love or feel lonely

Trouble communicating or being heard

Confusion or lack of intuition

Spiritual disconnection or depression

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QUESTION 2

Where is the Physical pain?

Please select all that apply.

QUESTION 3

Where is the Physical pain?

Please select all that apply.

Where is the Physical pain?(Required)

Lower back or legs

Lower abdomen or reproductive organs

Upper abdomen or digestive system

Chest or heart

Throat or neck

Forehead or eyes

Top of the head

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QUESTION 3

How do you feel Today about Life fulfillment?

Please choose one.

QUESTION 4

How do you feel Today about Life fulfillment?

Please choose one.

QUESTION 2

How do you feel Today about Life fulfillment?

Please choose one.

WHICH STATEMENT BEST DESCRIBES YOUR POSITIVE STATE OF BEING TODAY?(Required)

Grounded and secure

Joyful and fulfilled

Confident and empowered

Loving and compassionate

Authentic self-expression

Clear and intuitive

Connected to spirituality and purpose

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QUESTION 4

What do personal challenges look like?

Please select all that apply.

QUESTION 5

What do personal challenges look like?

Please select all that apply.

QUESTION 3

What do personal challenges look like?

Please select all that apply.

What do personal challenges look like?(Required)

Financial instability

Emotional imbalance

Low self-esteem

Trouble maintaining relationships

Difficulty expressing

Lack of clarity

Spiritual disconnection

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QUESTION 5

How do you feel about your creativity

QUESTION 6

How do you feel about your creativity

QUESTION 4

How do you feel about your creativity

How do you feel about your creativity(Required)

Blocked

Flowing

Not sure

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QUESTION 6

Do you feel comfortable expressing your desires or needs?

QUESTION 7

Do you feel comfortable expressing your desires or needs?

QUESTION 5

Do you feel comfortable expressing your desires or needs?

Do you feel comfortable expressing your desires or needs?(Required)

Always

Sometimes

Rarely

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QUESTION 7

Do you feel like you have found your purpose in life?

QUESTION 8

Do you feel like you have found your purpose in life?

QUESTION 6

Do you feel like you have found your purpose in life?

Do you feel like you have found your purpose in life?(Required)

Absolutely

Not sure

No

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QUESTION 8

How well do you sleep?

QUESTION 9

How well do you sleep?

QUESTION 9

How well do you sleep?

How well do you sleep?(Required)

Very well

Okay

Not well

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Whats Your Email?

Email(Required)