one-on-one intake form

Client Information

Thank you for filling out our one on one session intake form.
Your information is completely confidential and only used to support you during our session.

SET ASIDE SOME QUIET TIME FOR YOURSELF TO MEDITATE AND ANSWER A FEW QUESTIONS BELOW THAT WILL ASSIST YOU IN EXPLORING YOUR INTENTIONS AT YOUR SESSION. PLEASE GIVE IT YOUR FULL 100% ATTENTION AND ANSWER THE FOLLOWING QUESTIONS WITH AS MUCH DEPTH AS POSSIBLE.

ARE YOU READY FOR TRANSFORMATION? YOU WILL RECEIVE WHAT YOU PUT IN. PLAY FULL OUT!

* Indicates required field

One-On-One Session

Name *

First

Last

Email *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

How did you find out about Esther Jenkins or Andrea P. Lopez? *

Age *

Birthday *

Birthplace *

If you answered yes to children, what are their Ages and Gender? *

Occupation *

Religious Preference *

Untitled *

What moved you to sign up for a Session with Esther Jenkins or Andrea P. Lopez? *

What are your specific intentions for your Session? *

What are your unique gifts and what do you feel is your purpose in life? *

List all questions you would like Esther to address for you during the Session. Be specific. *

Health Questions

Have you previously experienced energy, Shamanic healing or any other therapeutic healing modality? *

Name of Present physician and/or health practitioner or Therapist *

Do you have any physical disorders, or health problems? Or history of them? *

Please list all previous major Illnesses, surgeries, hospitalizations and injuries and the year of occurrence. *

Are there any residual effects? *

Do you exercise regularly? If so, what form? How often? *

Do you smoke, drink or use any other form of mind altering substance? If so what, and how often? *

Are you currently on any form of medication, vitamins? If so, what type? *

PLEASE GIVE A DETAILED HISTORY OF YOUR RELATIONSHIPS WITH YOUR FAMILY, FOR EXAMPLE YOUR PARENTS, SIBLINGS, EXTENDED FAMILY, ETC. *

Is there anything else that you think I need to know, or that you would like to share? *

Submit

Private Session Intake

Client Information

One-On-One Session

Health Questions

Contact Us

Email: Phone Number:

Location:

Private Session Intake

Client Information

​One-On-One Session

Health Questions

Contact Us

Email: Phone Number:

Location:

One-On-One Session