INFORMED CONSENT and PROFESSIONAL DISCLOSURE STATEMENT: Oasis Health For Mood & Body DBA and The Art of Wellness PLLC

Jules Yuan Shellby, MA, NCC, LPC, ADS 231.944-8200 812 S. Garfield Ave., Ste. J, Traverse City MI 49686

Clients are advised to communicate with all other medical providers prior to treatment.

PROTECTING YOU:All healthcare treatments include possible risks; occasionally, detoxification procedures and/or counseling can lead to briefly feeling “under the weather”, which is a healthy response as your body purifies and processes. Following sessions, ensure maximum self-care and sufficient hydration. No information will be released without your prior consent, and no third parties shall be involved in your care; however, as a Mandated Reporter, Ms. Shellby must report persons who are a threat to themselves/others, or when a vulnerable person is in danger. To protect your confidentiality, Ms. Shellby will wait for you to greet her when out in the community, and will not acknowledge you if you do not do so. Women may initiate a brief hug upon departure with the door open.No tips or substantive gifts. Clients must be at least 18 (Eighteen) years of age and neither pregnant nor nursing. Oasis Health For Mood & Bodytreats only those persons capable of refraining from mentioning politics, religion, and/or mysticism.You may direct any unresolved complaints regarding acupuncture to NADA, PO Box 1066, Laramie WY 82073 (307) 460-2771; other concerns, see below.

PAYMENT: Full payment is due at Registration. Promotional prices are for electronic (credit/debit cards) transactions only.Receipts are emailed from a financial contractor. No cash accepted via mail; mailed payments must be money orders. No checks or billing.AoW provides no communication with third-parties, written or verbal, including insurance. LATE ARRIVALS: Sessions end at appointed time regardless of late starts due to client needs. TRANSFERRED/FORFEITED APPOINTMENTSare not eligible for rescheduling, refunding, or account credit. Appointments not attended (“No-Shows”) are charged as if attended. Appointments not attended within 10 minutes of appointed time are forfeited. Arriving with detectable use of DRUGS INCLUDING NICOTINE FORFEITS the appointment, including fumes on hair and clothing. Registrations, Gift Certificates, and Auction Certificates expire 30 days after date of purchase; Clients must phone The Art of Wellness to schedule. Payment for treatment may not be used for product purchases. REFUNDS: A $25 fee per Session will be assessed for all refunds. No refunds/account credit within 24 hours of appointments. Refunds for unused sessions must be requested within 24 hours of payment. No refunds/account credit for treatments received, regardless of outcome. Promotionally priced sessions are not eligible for refunds/account credit. RESCHEDULING: No rescheduling less than 24 hours prior to appointment for any reason including illness; appointments may be transferred as scheduled (client is responsible for all communication with Transferee). Promotionally priced sessions are not eligible for rescheduling. Appointments may be rescheduled no more than once per appointment. Product purchases are final sales; no returns/exchanges/account credit on products.Please do not request that these agreements be disregarded for you.

COUNSELING: The 55-minute sessions, which center on Cognitive Behavioral Therapy (“CBT”) and Directed Mindfulness Training, are $88.If you ever have concerns about the counseling, please know that you are encouraged to discuss them with Jules Yuan, who will do what she can to accommodate your needs, or will refer you toseveral different qualified professionals. It will be your responsibility to evaluate and contact any referrals. If you elect to terminate the relationship, you will be asked to participate in a termination session. If you are still dissatisfied or feel that she has acted unethically, unprofessionally, or illegally, you may file a complaint regarding counseling services by sending a written complaint to the Michigan Department of Licensing and Regulatory Affairs, Enforcement Division, Allegations Section, PO Box 30670, Lansing MI 48909, (517) 373-9196.

By signing below, you attest that: “I have read and understand all information above.For acupuncture, I will remain seated, keeping still while the fibers are in my ears. I will not bring non-clients to my session. The procedure was explained to me; I have discussed all questions, and have received or declined a copy of this form. I will not record the session. I consent to this treatment, agree to not hold any person or entity liable for any adverse or rare reactions that I may experience, or for my belongings, and accept full responsibility for my treatment.Oasis Health For Mood & BodyMAY _____ (initial if permissible) use my photo or video of me for promotional purposes including the website/Facebook page.”

Signature Printed Name Date

ABOUT YOUR EXPECTED RESULTS: No two people will have the same experience. The more “acute” your presenting concern, the more you’ll notice. Wellness is like disease: sometimes it’s perceived, but not always. Holistic care requires patience and persistence; it’s not like antibiotics. Oasis Health cannot guarantee noticeable outcomes; treatments address underlying causes and secondary symptoms.

ABOUT YOUR PRACTITIONER:Jules YuanShellby is a National Board Certified Counselor, a Licensed Professional (LPC), holds a Master of Arts Degree in Clinical Mental Health Counseling, holds a Master's Certificate in Substance Treatment, is a Registered Yoga Teacher, holds a Hypnotherapist Certificate, is a Hospice provider, brain injury expert, and combat PTSD Specialist (Center for Deployment Psychology, Washington, D.C.), isa Certified SMART Recovery Facilitator, a member of the Traverse City Chamber of Commerce, and is medicallysupervised by an M.D. She was clinically obese from childhood into her 30s, is a Weight Watchers International Lifetime Member, and has worked with thousands of clients in Colorado & Michigan since 1982.

Page 2 of 2CONFIDENTIAL CLIENT INFORMATION

Name: ______Other Name you go by? ______

Do you have symptoms of contagious conditions? __Yes __No Recently exposed to cold/flu? __Yes __No

Phone(s): Cell (_____) ______Do you text? __Yes __No Other Phone: (_____) ______

Email: ______Birthdate: ______

Mailing: ______

Had you heard about The Art of Wellness before today? __Yes __No If so, where? ______

Previous acupuncture? __Yes __No Auricular? __Yes __No If yes, in this region? __ Yes __ No If yes, from whom? ______

What Practitioners have you seen in the last 12 months? Name/Title; include DO,MD, NP, Chiro., CMT, PT, Reiki, etc. ______

______

Sensitivity to (circle): / Isopropyl Alcohol / Gold / Sterling Silver / Surgical Stainless Steel / Latex-Free Medical Tape

What type of digestive enzymes do you use? ______Do you eat only raw food? __Yes __No

Diagnoses, physical/mental/emotional: ______

Pharmaceuticals prescribed, last 12 months: name/reason: ______

What questions/concerns do you have regarding today's treatment? ______

What results would you like to see from this treatment? Circle ALL that apply, & specify below*, if needed:

REDUCE: / Portion-Size / Cravings for Refined Foods / Dieting / Boredom Eating / Emotional Eating
Stress / Worrying / SelfDefeating Talk/Behavior / People-Pleasing / Anxiety / Passivity
Insomnia / Oversleeping / Coffee / “Pop” / IBS / GERD / Indigestion
Obsession / Impulsiveness / Compulsion: / Spending / Intimacy-Seeking / Gambling/Lottery / Nail Biting
Acid pH / Fatigue / Pain / Tight Muscles / Stiff Joints / Headaches / Irritability
Resentment / PTS/D / S.A.D. / Depression / Perfectionism / Nicotine Withdrawal or Weight-Gain
Rescuing / Drugs: Alcohol / “As-Needed”** Prescriptions: / Anti-Anxiety Meds. / Pain Meds. / Other ** “PRN”
Moodiness / Judgmentalism / Feeling Overwhelmed / Menopause Features / Poor Self-Image
INCREASE & SUPPORT: / Memory / Circulation / Concentration / Immunity to Colds, Flu, Infection
Relaxing “Me-Time” / Dietary/Toxin Cleansing / Digestion / Energy / OpenMindedness / Well-being
Sports Performance / Recovery from Injury/Surgery/ Chemical Dependence / Libido / Healing

*Details/Other: ______

Who do you know who could benefit from treatment with Oasis Health For Mood & Body?

(You will earn generous referral benefits when they receive treatment, if they permit disclosure of treatment.)

Referral Name: ______Phone: ______May we phone them for you? __Yes __No

**Please Complete Reverse Side.**