Agreement for Wellness Services

View the full Agreement
Download the printable AWS

Practitioner Information
Name*
 
PMA License*
Email*
Street Address*
City*
   
Phone*
Practitioner Signature (type your name)*
Client Information
Name*
 
Email
Street Address*
City, State, Zip*
 
Phone
Client Signature (type your name)*
If you do not have an email address, please provide the name of someone authorized to communicate by email on your behalf to whom we can send a copy of this Agreement.

Name of Person Authorized to Receive/Send Email on Client's Behalf
The Person's Email Address
Phone

[honeypot honeypot-9364][honeypot honeypot-419]

How to Use This Form

This online facility is provided to help PMA Practitioners and their clients enter into the Agreement for Wellness Services (AWS).

The form above is used to submit the names and contact information of the parties signing the Agreement. The signatory information may be completed and submitted by either a PMA Practitioner or by a Client of a PMA Practitioner.

If you are a Client or prospective Client of a PMA Practitioner, please read the AWS carefully. It establishes the formal contractual relationship between you and your licensed provider of Pastoral Science & Medicine services.

The AWS Signing Process

Paragraph 18 of the AWS outlines the procedure the parties agree to follow in signing the Agreement using this online facility.  Here is how it works.

The signing process involves two steps: (1) using the form above to submit the parties’ names and contact information – which causes the system to send the Client and Practitioner the “Confirmation Email” referenced below; and (2) the Client thereafter replying by email to the Practitioner and PMA acknowledging receipt of the Confirmation Email and accepting the terms of the AWS.

In this way, the AWS is effectively signed and becomes binding upon both parties. A record of the transaction is created in PMA’s database, and the Client becomes a subscriber of the PMA Health Network.
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The Confirmation Email

When the names and contact information for the Practitioner and Client are submitted using the form on this page, the system automatically sends a Confirmation Email to the PMA Practitioner and the Client to the email addresses provided.

If the Client does not have or use email, the system will send the Confirmation Email to the person identified as being authorized to receive and send email on behalf of the Client. Obviously, it is important when entering information into the form to make sure the parties’ names and email addresses are written correctly.

Click Here to View a Sample Confirmation Email.

You will see that the first section of the Confirmation Email presents the names and contact information of the PMA Practitioner and Client exactly as that information has been entered in the form above.  If the name, phone number and email address of a person authorized to receive/send email on behalf of the Client has been provided, that information is included as well.

Additional sections of the Confirmation Email present “INSTRUCTIONS TO CLIENT“, “INSTRUCTIONS TO CLIENT’S AUTHORIZED AGENT” and “INSTRUCTIONS TO PRACTITIONER” indicating what to do next to complete the AWS signing process.

Basically, the Client or Client’s agent are instructed to (1) print and keep copies of the Confirmation Email and AWS, and (2) send an email (by clicking “Reply to All”) to inform the Practitioner and the PMA that the Client has received the Confirmation Email and accepts the terms of the Agreement.

The Practitioner is similarly instructed to retain copies of the Confirmation Email as part of his / her Client records, as well as a copy of the email received from the Client or Client’s agent acknowledging receipt of the Confirmation Email. The Practitioner is further advised to contact the Client or Client’s agent if the Practitioner has not received email notice that the Client, in fact, received the Confirmation Email.
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Practice Disclosure Statement

Note that Paragraph 2 of the AWS refers to a “Practice Disclosure”, which is a written statement the PMA Practitioner should give to every client at the time of entering into the Agreement describing “the Practitioner’s education, training and experience in the services to be provided”.

Delivering the required Practice Disclosure will also be accomplished by the use of the above form in the near future. In the meantime, PMA Practitioners should deliver their written Practice Disclosure to their clients directly. If you are a Client and you have not yet received a written Practice Disclosure from your PMA Practitioner, please be sure to ask your Practitioner for it.

Signing the AWS Physically

For your mutual protection, even if you are printing out and signing the AWS physically, either the Practitioner or the Client should complete and submit the above form to create a record in the PMA’s database of your entering the Agreement and to be sure that all clients are subscribed to the PMA Health Network as provided in the AWS.
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Please feel free to Contact Us if you have further questions about how to use this form.