New Client Application – Alternative Approach Wellness Center

Our current estimated waiting list is 6-9 months.

Please fill out the application below.

Name *

First

Last

Date of Birth *

Street Address *

City, State, ZIP code *

Phone # *

Email *

How did you hear about us/who referred you? *

Ashley only takes on clients that she believes she can help. Please give a brief description of your condition/symptoms. *

The first appointment typically takes 1.5-1.75 hours. Preferred appointment time. *

Morning 9am-12pm
Afternoon 1pm-4pm

This form must be filled out by the person listed above, unless that person is a minor. The goal of this form is to give you an idea of what to expect from Ashley, and what Ashley will expect from you. Ashley is here to work with clients who are willing to make changes. Various conditions can be caused by poor health choices and you cannot "supplement" your way out of a condition that you "behaved" yourself into. If you are willing to make changes, please initial below. If not, please do not apply. *

Ashley may recommend evaluating your lifestyle. Going to bed at a reasonable hour, getting enough sleep, minimizing stress where possible, moderate exercise, staying hydrated, etc. *

Diet is very important to healing. Some foods can cause inflammation or the body can become sensitive to certain foods. Ashley may suggest avoiding sugar, gluten, dairy or other foods for a period of time or perhaps as a long term change. *

Weight loss is not our priority, though typically changing diet and lifestlyle can help a lot. The Standard American Diet does not promote health. Ashley recommends starting the Whole 30 diet to get you started in the right direction. *

Ashley does use supplements and homeopathics to help support your body during the healing process. Some are recommended for a shorter period and some may be recommended for a longer period as they may be necessary due to lifestyle stress or lack of proper nutrition in food. *

Do you have active cancer and/or are undergoing cancer treatment? *

If yes, please explain. Ashley is very limited in what she is as able to recommend during cancer treatment. She does not specialize in cancer treatment.

Are you pregnant, trying to become pregnant, or nursing? *

If yes, please explain. Ashley is very limited in what she is able to recommend during pregnancy/nursing. She does not specialize in fertility.

Ashley recommends that it is important for "mom" to work on her own health before trying to become pregnant. If you have a firm timeline for becoming pregnant, now is not the time to start working with Ashley as it can take as many as 18-24 months (or more) to work on your health challenges.

Ashley is not a behavioral therapist. Some physical challenges can cause behavioral issues, especially in children, but there is no "supplement" that will make your child behave. *

If you are taking medications and are willing to list them below, we need this information to understand if there would be any interactions.

I understand that healing takes time. It took time for my condition to develop. It will take time to correct. A typical client is working with Ashley with appointments every 4 to 6 weeks initially and usually for a period of 18-24 months or more depending on the condition and length of time you have had it. Clients will typically then "graduate" to being seen every 6-12 months, or on more of an as needed basis. *

I understand that this form is an application that will be evaluated. *

Phone