Zen Remedy & Mindful M3

Child & Family Intake Acknowledgment and Service Disclaimer

Welcome to Zen Remedy!
Before we begin, please read and acknowledge the following so we can ensure a clear, supportive, and safe working relationship.

Section 1

1. About My Role

I, Shu (Joshua Shumelda, Founder of Zen Remedy), am a certified lifestyle mentor and guide.
I am not a licensed psychotherapist, psychologist, counselor, or medical provider.
My expertise includes certifications in neuropsychotherapy (NPT-C), cognitive behavioral therapy (CBT), and other evidence-based modalities.

2. Scope of Services

I offer practical, science-based strategies to support children’s social-emotional growth, resilience, and well-being.
My work integrates body-based (“bottom-up”) and cognitive (“top-down”) tools—such as breathwork, mindful movement, CBT, and NLP—to help with self-regulation, emotional intelligence, and healthy relationships.
My guidance is educational and supportive, not clinical or medical.

3. What to Expect

Families seek my services for support with stress, emotional triggers, self-regulation, focus, and healthy lifestyle design.
I use the Lifestyle Architecture framework to help children and families build purposeful, healthy habits.
My programs are solution-focused, collaborative, and grounded in current science.

4. Important Disclaimers & Legal Notices

Please read and check each box to indicate your understanding and agreement:

I understand that Shu (Joshua Shumelda) is not a licensed psychotherapist, psychologist, counselor, or medical provider.

I understand that Zen Remedy’s services do not include diagnosis, treatment, or therapy for mental health or medical conditions.

I understand that Shu’s (Joshua Shumelda) services are not a substitute for professional healthcare, mental health, or crisis intervention.

I understand that if my child requires clinical care, I will seek help from a qualified healthcare professional.

I understand that participation in Zen Remedy programs does not establish a therapist-client or doctor-patient relationship.

I understand that information shared will be kept confidential within the limits of the law, and that Shu is a mandated reporter in Alaska.

In the event of a crisis or emergency, I will contact emergency services or a licensed mental health professional.

Section 2

It is my choice to receive treatment. I understand that the information given below is strictly confidential and will be for no other purpose than to assist the facilitator in providing a suitable session which would take into consideration my specific requirements.

Name

First Name

Last Name

Are you on Facebook?

Yes

Phone

(###)

###

####

Email Address

Personal Wellness Information

Birthday

For special Bonus in your birth month

YYYY

Please list any forms of medication or herbal supplements you are taking

Any other Care or Concerns

Commitment and Consent for Care

Lifestyle Architecture is intended to educate me about the dynamics of health that are within my control, including patterns of movement and holding, responses to stress, and accumulation of tension. It is a holistic approach to bridging mind and body. Together we will assess physical signals of diminishing health and develop a treatment plan to respond to them in ways that promise vitality, balance, and spirit. Selecting "Yes" below indicates my willingness to proceed. Information provided to me by the facilitator is for educational purposes and is not a claim for cure or mitigation of disease, but rather an adjunctive approach, supplying individual needs that otherwise might be lacking in today’s lifestyle. I understand that my well being is in direct relation to how well I treat my being.

Select

Address for at home sessions

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

What time of the week and day is best for you? We will contact you when we recieve your submission to schedule and confirm a time

Zen Remedy & Mindful M3

Child & Family Intake Acknowledgment and Service Disclaimer

1. About My Role

2. Scope of Services

3. What to Expect

Disclaimer

My Zen Remedy