Your Alignment Assessment
Please take a moment to answer the questions below
Client Intake Questionnaire
Rows
Yes
No
Unsure
Sometimes
Often
Are you new to Spinal Energetics?
Have you worked with energy or received an energy healing modality?
Are you currently experiencing stress?
Do you find it difficult to relax or slow down? Does your body remain tense even when you’re trying to relax?
Do you feel disconnected to your body?
Do you feel disconnected from your emotions?
Do you spend time connecting with your body or do you have a regular practice such as meditation, yoga, energy clearing and etc…
Have you experienced physical trauma or accidents? (Please mention where in second text box below.) Is it bothering you today?
Are you experiencing unexplained pain or reoccurring tension?
Do you have any issues with your spine? Examples: scoliosis, stenosis, herniated disk, degenerative disk disease, muscle strain, loss of curvature and pain. Please mention which part of spine or which vertebrae in second text box. Upper cervical, lower cervical, thoracic, lumbar, sacrum or coccyx.
Do you have cold hands and feet?
Check yes if you have any of these: obsessive thinking, low quality sleep, procrastination and difficulty switching off.
Check yes if you have any of these: feelings of uncertainty around identity, purpose, and self-expression. Questioning the purpose of life, feeling unworthy.
Check yes if you have any of these: relationship trauma, overwhelmed sense of responsibility, feeling closed off to self and others, loneliness and desire for connection?
Check yes if you have any of these: feelings of uncertainty, instability, inflexible, repressed emotions and insecurity.
Check yes if you have any of these: feelings of doubt, difficulty making decisions, easily persuaded by others, seeks approval, not confident and self-abandonment.
Check yes if you have any of these: anxiety/panic attacks, instability, concern of past and future, fearful, in survival mode, sensitive and reactive to environment and people.
What would you like support with today?
Is there anything in your body that feels new, unfamiliar or simply worth mentioning today?
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