Chakra Healing Intake Form

Every website has a story, and your visitors want to hear yours. This space is a great opportunity to give a full background on who you are, what your team does and what your site has to offer. Double click on the text box to start editing your content and make sure to add all the relevant details you want site visitors to know.If you’re a business, talk about how you started and share your professional journey. Explain your core values, your commitment to customers and how you stand out from the crowd. Add a photo, gallery or video for even more engagement.

First Name

Last Name

Birthday

Goals and Intentions

What brings you to chakra healing?

What specific goals or intentions do you have for this experience? (e.g., emotional balance, stress relief, spiritual growth)

Are there specific areas of your life where you feel stuck or in need of support?

Energy Self-Assessment

Chakra Focus Areas

Are there specific chakras where you feel blockages or imbalances may have resurfaced? (Select any that apply and describe)

Healing Practices and Daily Routine

Have you continued with any practices or techniques from our last session (e.g., meditation, breathwork, journaling)? If so, how have they been helpful?

Are there any new practices you would like to explore or revisit in this session?

Challenges and New Intentions

Are there any current challenges or stressors that have emerged since our last session?

Is there a specific intention or area of focus you’d like to set for today’s session?

Additional Thoughts or Insights

Is there anything else you would like to share?

Thanks for submitting!