New Client Informed Consent Form
California Senate Bill SB-577, effective January 1, 2003, enables complementary and alternative health practitioners to provide and advertise their services legally, according to certain rules of compliance specified in the legislation. Section 2053.6 of the California Business and Professions Code requires the following disclosures:
What does Senate Bill SB-577 mean for you, the patient?
SB-577 gives you access to alternative and complementary health care practitioners. You must be given information about the nature of treatment and the practitioner’s qualifications. Feel free to ask a practitioner any question you might have about your treatment. Check to see if your practitioner has been certified by a professional membership society. In addition, tell your doctor about any alternative treatment you are pursuing. You can also request that your licensed and unlicensed health care providers communicate with each other and work collaboratively to meet your health care needs.
SB-577 helps to protect you. SB-577 requires unlicensed alternative health care practitioners to follow certain guidelines and restrictions.
Here are the things that unlicensed alternative practitioners are NOT allowed to do:
- Perform any form of surgery or any procedure that punctures your skin or harmfully invades your body.
- Use X-ray radiation.
- Prescribe prescription drugs, or recommending that you discontinue drugs that were
prescribed by a licensed physician.
- Set fractures.
- Treat wounds with electrotherapy.
- Put you at risk of great bodily harm, serious physical or mental illness, or death.
- Imply in any way that they are licensed physicians.
Disclosure to the client in plain, written language that:
- that the practitioner is not a licensed physician;
- that the treatment is a complementary or alternative healing modality and not
licensed by the state;
- the nature of the service to be provided and the theory of treatment upon which the services are based; and
- the practitioner‘s education and other training, experience, and other qualifications regarding the services to be provided.
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I understand that Sherry Mosley is not a licensed physician in California and does not possess a license from the state of California.
I also understand that the Shamanic Akashic Record consult and healing practices and Asian Medicine practices of acupoint therapy, Chinese herbal medicine, nutriton and diet consult, lifestyle coaching, medical Qigong and Reiki are all forms of complementary and alternative medicine not licensed by the State of California. I can offer you these services, subject to requirements and restrictions that are described in this document. In practicing complementary and alternative medicine Sherry Mosley seeks to support rather than replace the care of your existing doctors and practitioners.
As a practitioner of Asian Medicine practices of acupoint thereapy, herbal medicine, nutrition and diet consult, lifestyle coaching, medical qigong, Reiki, Shamanic Akashic Record Consults and Healing and Shamanic Practices, I will provide you with the following kinds of services:
- Chinese Herbal Medicine is a highly complex system of single herbs and formulas used to rebalance the body internally prescribing formulas particular to one’s tongue and pulse diagnosis and their symptoms. Herbs are usually in a powder form to make a tea or in pill form. They are best taken for a week to see results. Herbs should be stopped if any uncomfortable side effects are experienced or if an exterior illness is contracted consult with the practitioner on if to take exterior illness herbs you already have on hand from the practitioner.
- Acupoint Therapy uses a system of points all over the body, called acupoints, on the energy systems of the body called meridians, which are heightened areas of the body’s energy and are connected to the body’s organ systems, spirit, and mind or emotional well being. Thus these points have the ability to assist the body in it’s natural ability to heal activating these areas in rebalancing it’s physical, emotional and spiritual state helping restore one’s health and well being. Acupoint therapy using a gold or silver mini wand, aromatherapy oils or Mugwort (placed on point and lit with incense to add warmth, build and move the body’s Qi and blood. Heat will be felt by the patient at which point they can say “hot” and minimal non permanent scarring is not intended but can happen on very rare occasion) does not puncture the skin and is only placed on the surface of the skin on acupuncture points to activate the point's energy.
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Nutrition & Dietary Consulting includes Asian medicine theory of many foods including certain energetic properties that can positively assist or negatively impact one's health. I will go over what you are currently eating regularly and how to improve your daily food choices for optimal harmonizing of your individual constitution.
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Lifestyle Coaching includes us going over what you do day to day (sleep, work, exercise, relationships) and seeing where simple daily improvements can be made so you will be living your best choices for being in harmony with you are as an individual and not just following societal standards.
- Shamanic practices use altered states of consciousness which at certain times are attained through consciousness-changing techniques involving a monotonous percussion sound (at 4-7 hertz), done with a drum or rattles and other instruments. While in this altered state the shamanic practitioner (Sherry Mosley) or client connects with the spirits to ask for healing or/and knowledge and wisdom to get information. Shamanic healing practices work at healing the spiritual aspects of illness which can appear in emotional and physical forms.
- Shamanic Divination and Akashic Record services given for your own personal needs on problem solving to receive guidance, wisdom and healing from the spirits, nameless beings of light, Lords and Masters of the Records, past on loved ones in the name of your Soul’s highest purpose. This wisdom is accessed via a shamanic journey with drumming or by using an Akashic Record access prayer with your full legal name. Doing work in the spiritual realm and in your soul’s record creates energetic shifts removing blocks and illness from a spiritual or soul level, often considered the root of many illnesses.
- Shamanic Journey lessons teach you to do your own shamanic journey work for your own problem-solving, guidance, consciousness ascension, wisdom and personal healing. Akashic Enlightenment classes teach you how to access your own Akashic Records for your own problem-solving, guidance, consciousness ascension, wisdom and personal healing.
Educational Qualifications and Training to Practice Asian Medicine practices of acupoint thereapy, herbal medicine, nutrition and diet consult, lifestyle coaching, medical qigong, Reiki, and Shamanic and Akashic Record Practices:
- Akashic Knowing - San Rafael, California
- Certificate, Course 1:Access Your Personal Akashic Record Wisdom - April 2016
- Certificate, Course 2:Akashic Self Mastery and Self Love - May 2016
- Certificate, Course 3: Access Akashic Records Wisdom for Clients, Akashic Career Mastery - October 2016
- Center for Akashic Studies - Chicago, Illinois (online)
- Certificate, Healing in the Akashic Records - October 2015
- Certificate, Manifesting Your Soul's Destiny in the Akashic Records - December 2015
- Acupuncture & Integrative Medicine College (AIMC) - Berkeley, California
- MSOM (Masters of Science, Oriental Medicine), December 2014
- Clinical Experience, AIMC Clinical Intern & Herb Disp., May 2012 - Dec 2014
- Education & Training, Japanese Moxa & Meridian therapy, April 2012 & 2013
- Certificate, Japanese Contact Needling, Dr. Bear, March 2012, Sept 2013
- Certificate, Medical Qigong Module I, October 2011
- Certificate, J.R. Worsley Five Element Acupuncture Diagnosis, August 2007
- Foundation for Shamanic Studies - San Francisco, California
- Certificate, Harner Shamanic Counseling, August 2010
- Certificate, Shamanic Healing, April 2010
- Five Element Acupuncture Trainings - San Mateo, California
- Certificate, Five Element Acupuncture Diagnosis Apprenticeship, May 2009
- Healer In Light - San Francisco, California
- Certificate, Reiki Level III w/ Shamanism, January 2009
- Certificate, Reiki Level II w/ Shamanism, January 2008
- Certificate, Reiki Level I w/ Shamanism, October 2007
If you ever have any concerns about the nature of your treatment, please feel free to discuss them with me. I recommend that you inform your medical doctor, and/or other practitioners you are seeing and find applicable, that you are receiving Asian Medicine, Shamanic and/or Akashic Record sessions.
Please acknowledge receipt of the information provided in this form and that you sign it. You will receive a copy upon request. I will keep the original in my records for at least three years.
Cancelation Policy
Please arrive on time for your appointments. If you are more than 15 minutes late, you may not be able to be seen and will be billed for your reserved treatment time. Please give at least 48 hours notice of cancellation to avoid a late cancellation charge. Patients will be charged full current treatment fee for late or missed appointments on their following provided credit card or asked for this payment with check or cash at the next appointment unless time slot is filled by another patient.
Acknowledgement and Consent to Receive Services:
I have read and understand the above disclosure about the Asian Medicine, Shamanic Akashic Records sessions and trainings offered by Sherry Mosley and Sherry Mosley’s training and education. I have discussed with Sherry Mosley the nature of the services to be provided. I understand that Sherry Mosley is not a licensed physician and that the Asian Medicine, Shamanic Akashic Record services she offers are not licensed by the state. I understand it is my responsibility to maintain a relationship for myself/my child with a medical doctor. I have consented to use the services offered by Sherry Mosley, and agree to be personally responsible for the fees of Sherry Mosley in connection with the services provided to me.