CHAKRA ASSESSMENT

Name *
Name
ROOT CHAKRA
Physical Symptoms
Select all that apply
Mental/Emotional Symptoms
Check all that apply
SACRAL CHAKRA
Physical Symptoms
Check all that apply
Mental/Emotional Symptoms
Check all that apply
SOLAR PLEXUS CHAKRA
Physical Symptoms
Check all that apply
Mental/Emotional Symptoms
Check all that apply
HEART CHAKRA
Physical Symptoms
Check all that apply
Mental/Emotional Symptoms
Check all that apply
THROAT CHAKRA
Physical Symptoms
Check all that apply
Mental/Emotional Symptoms
Check all that apply
THIRD-EYE CHAKRA
Physical Symptoms
Check all that apply
Mental/Emotional Symptoms
Check all that apply
CROWN CHAKRA
Physical Symptoms
Check all that apply
Mental/Emotional Symptoms
Check all that apply
CASSIE'S USE ONLY
INTENTIONAL HEALING FORM
This can be emotions, thoughts, patterns that no longer work, and/or limited beliefs not serving you.