New Patient Intake Form

Welcome to the Akasha Center. At The Akasha Center, we emphasize the team approach to wellness,
prevention and treatment of disease. This teamwork is achieved through regular patient-centered
meetings among the practitioners at Akasha, and through our partnership with you. Our purpose is to
help you to achieve your health-related goals. In order to do that, we need to work together with you. That
means that you will be invited to participate as actively as possible in the work we do together.

The first step in that process requires you to commit time and energy to providing us with the
information we require in order to best be of service to you. This health and wellness history may be
more extensive than others you have completed. While we will certainly ask more questions of you in
person in order to understand your health concerns and goals, it is helpful for the process for you to
complete this form as thoroughly as possible. By completing this form in advance of your visit, you will
allow us to make the best use of our time together, focusing on the issues most important to your overall
health. However, you may choose to answer only the questions with which you feel comfortable.

The form goes into detail about your physical, mental, emotional and spiritual health. Please answer all
questions as comprehensively as possible. We ask you to set aside some time to complete this, in a place
where you can focus your attention on yourself.

Please bring any appropriate medical records, x-ray reports, and pathology or lab reports with you to
your first visit.

We provide many services which are considered complementary to the western medical approaches most
commonly reimbursed by typical insurance companies. Insurers vary in their rules regarding
reimbursement for psychotherapy, acupuncture, massage therapy and other modalities. Because of the
changing nature of this system, private payment is necessary for our services at the time of your visit.
We will provide all necessary documentation to you in order for you to submit a claim for
reimbursement to your insurer.

Once again, welcome to our Center. We look forward to becoming health partners with you.

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