Self Assessment - Energy Release

Full Name *

Email (optional, so I can match this to your file)

Right now (at this hour), I feel most...

Where do you most often hold tension or discomfort?
Neck & shoulders
Upper back
Lower back
Chest
Stomach / gut
Head
Hips & pelvis
Legs

Other:

Lately, I notice myself experiencing:
Anxiety or racing thoughts
Fatigue or low energy
Disconnection or feeling foggy
Emotional heaviness or sadness
Restlessness or irritability
Physical tension
Trouble sleeping

Other:

Is there an area of your body asking for attention right now?

Check what applies (I feel...):
Stuck
Anxious
Overwhelmed
Disconnected
Heavy
Blocked
Peaceful
Grounded
Hopeful

Other:

What are you hoping to receive from this workshop?

Have you experienced energy work, Reiki, or chakra clearing before?
Yes No Not sure

Is there a chakra or energy center you feel most drawn to or blocked in?
Root
Sacral
Solar Plexus
Heart
Throat
Third Eye
Crown
Not sure

On a scale of 1-10, how connected do you feel to your body right now?
Select... 1 2 3 4 5 6 7 8 9 10

Any recent life changes, stress, or events you'd like me to gently be aware of?

Any physical sensitivities, injuries, or areas to avoid touching/focusing on?

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