FINANCIAL RESPONSIBILITY AGREEMENT

This Financial Responsibility Agreement (“Agreement”) is entered this day of , 20(“Effective Date”), between The Sanctuary at Sedona Inc., located at 2675 W. State Route 89A, #1115, Sedona, Arizona 86336 (“The Sanctuary”) and {name} whose address is (“Resident” or “you”). The Sanctuary and Resident agree that the following terms govern the provision of the Holistic Addiction Recovery Program (“Program”) by The Sanctuary to Resident and the compensation of Resident for that Program.

A.Program Fee:

1. Single Room: The Program Fee for Resident is Thirty-Six ThousandDollars ($36,000) based on a thirty (30) day stay. If your stay is shorter than 30 days, you will be charged on a pro-rata basis and will incur Use and Severance Tax (See Appendix A, The Sanctuary at Sedona Inc. Statement of Intent to Lodge in Excess of Thirty (30) Days, attached).

2. Double Room: The Program Fee for Resident is Thirty-Four Thousand Dollars ($34,000) based on a thirty (30) day stay. If your stay is shorter than 30 days, you will be charged on a pro-rata basis and will incur Use and Severance Tax (See Appendix A, The Sanctuary at Sedona Inc. Statement of Intent to Lodge in Excess of Thirty (30) Days, attached).

Room and board, and all Program sessions are included in the Program Fee. As provided in this Agreement, you are responsible for all other costs and expenses.

Upon admission, you will receive an invoice stating the Program Fee and reflecting your payment. This will not be an itemized invoice of the kind required by insurance.

B. Payment: Payment of the full Program Fee must be made prior to, but no later than, arrival at The Sanctuary. You may pay by wire transfer, EFT, personal check, cashier’s check, PayPal, or by credit card. Post-dated checks will not be accepted.

Any dishonored payment (such as an insufficient funds check or disputed credit card charge) will be charged interest at the rate of 18 percent per year until fully paid. You will also be responsible for all cost of collections (including collection agency fees which may be 1/3 of the amount of the debt) plus all bank or credit card processing fees The Sanctuary incurs as a result of the dishonored payment.

C. Commitment Fee: you schedule your admission more than five days in advance of the date you intend to arrive, you must pay Commitment Fee of $5,000.00 to reserve your room. In the event, you change your mind prior to scheduled arrival date, a refund may be issued under the following circumstances:

1. If notice of the cancellation is received more than 14 days prior to your arrival date a $500.00 administrative fee will be charged and $4,500.00 will be refunded to you; or

2. If notice of the cancellation is received less than 14 days prior to your arrival date, your entire Commitment Fee will be forfeited, and no refund will be issued.

To cancel your reservation, you must provide notice to The Sanctuary by email info@sanctuary.net.

The Commitment Fee, once paid, is applied toward the balance of the Program Fee.

D. Transfer and Self-Discharge

1. The The Sanctuary reserves the right, at any time, to refer or transfer any Resident to a different or higher level of care based on its evaluation of a Resident’s needs, or to discharge a Resident because they are unable to engage in or progress in treatment, also known as aTherapeutic Discharge. You understand the transfer or discharge is believed to be in your best interest and is not grounds for seeking a refund of any Program Fee incurred prior to the date of the transfer or discharge or the Administrative Fee specified below.

2. If a Resident receives a Therapeutic Discharge, that is, is transferred to a different or higher level of care or is discharged because they are unable to engage in or progress in treatment,the Resident will be assessed an Administrative Fee of $5,000.00plus a daily fee of $1,200.00 (“Daily Fee”) for each day the Resident was in the Program. If the Program Fee paid by the Resident exceeds the total of the Daily Fees and the administrative fee plus all applicable taxes, a refund will be issued to the Resident. All applicable sales and use taxes will be deducted from any refunds issued. Refunds will be processed within 30 days of the Resident leaving the Program.

3. If a Resident Self-Discharges prior to Day 18 of the 30 day program the Resident will be assessed an Administrative Fee of $5,000.00 plus a daily fee of $1,200.00 (“Daily Fee”) for each day the Resident was in the Program. If the Program Fee paid by the Resident exceeds the total of the Daily Fees and the administrative fee plus all applicable taxes, a refund will be issued to the Resident. All applicable sales and use taxes will be deducted from any refunds issued. Refunds will be processed within 30 days of the Resident leaving the Program.

4. If a Resident Self-Discharges on Day 18 or after of the 30 day program the Resident there will be no refund issued to the Resident.

E. Non-Program Costs: Unless otherwise provided in this Agreement, the Program Fee does not include the cost of medications, Medical Care Costs, Psychiatric treatment or counseling, testing/laboratory work, or the costs of outside providers. You agree to pay these costs. You also agree that upon admission, or upon any subsequent request, you will provide your original insurance card or an enlarged copy of the front and back of the card to us. In the event your insurance coverage changes during your stay, you agree to notify The Sanctuary immediately and provide a new original card or an enlarged copy of the front and back of your new card. The Sanctuary will relay this information to any outside providers to assist you in arranging for payment of the following costs.

Regardless of the assistance we may provide in relaying insurance information, you agree that you will make payment arrangements with all providers sufficient to cover the cost of the following:

1. Medication or Prescriptions including the payment of all co-pays, deductible, or uncovered medications.

2. Medical Care including any charges for ambulance transport to a hospital, non-emergency medical transport, emergency room, hospital, urgent care, doctor visits, or other medical treatment and all co-pays, deductibles, or non-covered treatment.

3. Psychiatric Care including all co-pays, deductibles, or non-covered treatment. However, the Program Fee does cover the costs associated with an initial evaluation by The Sanctuary’s Psychiatrist, but not the cost of any recommended lab tests, studies, or subsequent treatment.

4. Laboratory/Testing costs including all co-pays, deductibles, or non-covered expenses. The Sanctuary’s Psychiatrist may recommend lab work or testing during the initial evaluation, the cost of any recommended lab work or testing is not included in the Program Fee.

None of the foregoing providers will be permitted to bill The Sanctuary for services provided to you. You are solely responsible for filing any insurance claims for reimbursement for amounts paid for the foregoing services.

F. Supplement Costs: You will be provided The Sanctuary “Power Up Your Brain” initial Supplement Protocol and the cost of this initial Supplement Protocol is included in the Program Fee. Any additional supplements are not included in the Program Fee and you are responsible for payment of any additional supplements/vitamins.

G. Property Damage: If you cause or contribute to any damage to The Sanctuary’s property, you will be charged for the cost of repair. If the property cannot be repaired, you will be charged the cost to replace the damaged property.

H. No Guaranty: You understand The Sanctuary does not make any guarantees whatsoever, expressed or implied, regarding the effects, outcomes, or success of your participation in the Program or The Sanctuary’s services. You understand that you are responsible for the fees set forth in this Agreement regardless of the effect, outcome, or success of your participation in the Program or from The Sanctuary’s services.

I. Termination: Except as otherwise provided herein, this Agreement shall remain in full force and effect until Resident leaves The Sanctuary; however, Resident’s obligation to pay any unpaid fees or costs is not extinguished by the termination of this Agreement. Further, paragraph I above, will not be affected by any termination of this Agreement.

J. Severability: Should any provision of this Agreement be declared invalid or unenforceable, the remaining portions of the Agreement shall not be affected and this Agreement shall be construed in all respects as if such invalid or unenforceable provision was omitted.

K. Choice of Law and Venue: It is the intention of the parties to this Agreement that the laws of the State of Arizona shall govern the validity of this Agreement, the construction of its terms, and the interpretation of the rights and duties of the parties, without giving effect to any choice or conflict of law provision or rule. Any action involving or relating to this Agreement shall be brought in the state court of Yavapai County, Arizona. The prevailing party in a legal action to enforce this Agreement is entitled to reasonable attorneys’ fees and court costs incurred.

L. Successors and Assigns: The Sanctuary and Resident each binds itself and its successors, executors, administrators, and assigns to the other parties of this Agreement and to the successors, executors, administrators, and assigns of such other party, in respect to all covenants of this Agreement.

M. Headings: Section headings are not part of this Agreement and are not intended to be a full and accurate description of the contents hereof, they are merely illustrative.

N. Waiver: Waiver by one party of a breach of any provision of this Agreement by the other party shall not operate as or be construed as a continuing waiver.

O. Modification or Amendment: This Agreement may be modified or amended ONLY if the amendments are made in writing and signed by both parties.

P. Entire Agreement: This Agreement sets forth the entire agreement between the parties, and replaces and supersedes any and all other contracts, agreements, and understandings, written or oral, relating to the subject matter hereof.

I, {name} acknowledge by my signature below that I have completely read this Agreement, understand the contents thereof, have had the opportunity to have any of my questions about this Agreement answered, and am willing and capable of providing the resources necessary for successful completion of The Sanctuary’s Program, and that I am signing this Agreement freely and willingly.

Furthermore, I understand the payment and refund policy outlined in this Agreement.

(Printed Name)

(Address)

(City, State, Zip)

(Telephone)

(Email)

(Signature)

(Date)