Form cover
Page 1 of 1

The Alignment Assessment for Your Healing Blueprint

This is a short, private self-assessment; I pair it with a remote body scan using Emotion Code. The combination is designed to pinpoint the highest-impact stress patterns affecting your wellbeing, focus, and emotional bandwidth—and to translate what you’re carrying into a clear, prioritized next step. Time: ~7 minutes. I will review your responses confidentially and create your PERSONALIZED HEALING BLUEPRINT based on the results. Please allow up to 3 days to receive your Blueprint.

Email

First Name

Last Name

Profession

Date of Birth

In the next 30 days, what would make the biggest difference to your quality of life and leadership performance?

Which constraint feels most emotionally taxing right now?

Your workload intensity most weeks is...

A
B
C
Standard scale settings (use for every linear scale question) 1 = Not an Issue & 5 = Consistently an Issue

Sleep quality (restorative sleep, not just hours)

Daytime energy stability (no major crashes)

Stress load (how “full” your system feels)

Recovery capacity (how quickly you bounce back after intense days)

Emotional steadiness (less reactivity, more composure)

Wired-but-tired (tired but can’t fully rest)

Difficulty switching off (mind keeps running at night)

Physical tension (jaw/neck/shoulders/back)

Reliance on stimulants (caffeine/sugar) to function at your current pace

Cognitive clarity (clean thinking, prioritization, decision quality)

Sustained focus (staying on one thing without drifting)

Boundary integrity (protecting time, saying no, not overcommitting)

Context switching (meetings/notifications fragmenting your day)

What’s one symptom or pattern you don’t want to normalize anymore?
Note: keep to 1 sentence.

What have you tried that didn’t stick—and why do you think it didn’t?
Note: keep to 1–2 sentences.

Under pressure, which pattern shows up most?

A
B
C
D
E

Receiving support feels:

A
B
C