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Aspire Wellness Center Patient Intake Form

Patient Intake Form

Please list tested or suspected allergies or sensitivities and related symptoms:

Please list any prescription medications or over-the-counter medications you are taking.

Please read the New Patient Information form. Sign below when you have finished.

Our Forms

Please download these additional forms and take them with you upon your visit.

PSYCH-K Facilitator

The purpose of the organization includes but is not limited to: Naturally, empowered wellness.

Personalized to meet individual’s goals and beliefs.

Transformation in the way one thinks using multi-functional and multi-disciplinary techniques.

 
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Care for your body

Are you ready to start living your best life?

AAT & PSYCH-K®alternatives guide your inner wellness & peace. It will bring you back to how it was intended for you to live.

Healthier
93%
Healing
90%

New Patient Information

In order to receive the best possible results, it is important to read and understand the following information:

  • Some cases may require treating preliminary items that are contained within a substance, such as vitamins, minerals, phenolics and/or sugars. For example, sugar may need to be addressed before proceeding with alcohol, grains or fruit.
  • After addressing any preliminary items, patients may choose what order remaining substances are treated.
  • It is possible to treat numerous items in one session if they are all part of the same family. For example, all dairy products (milk, cheese and yogurt) and calcium may be treated together. But dairy and wheat, or tomatoes and pollens may not be addressed in the same session. The treatment will not be successful.
  • We cannot guarantee how many sessions each substance will require to reduce the symptoms associated with that item.
  • When addressing a condition, instead of a single substance or family of substances, multiple items may be contributing to the symptoms. Therefore such conditions may require multiple sessions to relieve the symptoms of the condition.

Please adhere to the following guidelines:

  • As a courtesy to our other patients who may have strong sensitivities, please do not smoke or wear perfume or fragrances prior to coming in to the clinic.
  • Do not eat or chew gum during the session.

Office Policies

  • The clinic has a 24-hour cancellation policy. Late cancellations or no-shows will incur a charge of ________.
  • Please arrive 10 minutes prior to your appointment time. Late arrivals may be rescheduled and will incur a charge of ________.
  • Payment is due at the time services are rendered.