Health and Wellness Agreement With Fee Chart

In the Agreement below, Timothy J. Ryan, Ph.D., D.Div., is referred to as your “Practitioner,” you are referred to as the “Client.” For the purposes of this agreement, Faith Based Counseling, Pastoral Counseling and Therapy, Success Life Relationship – Returning To Love Skill Training Coaching and Spiritual Direction, Healing and Transformation are all considered “Wellness Services” under this contract agreement unless otherwise stipulated.

1. Education: Client understands that Dr. Timothy Ryan’s education includes: a Bachelor in Psychology, a Masters in Counseling and a Doctorates in Clinical Psychology as well as a Doctorate in Divinity. He practices as a Pastoral Individual Relationship Counselor/Therapist, an Ordained Minister, Intuitive Energy Healer and Wellness Practitioner.

    

2. Practitioner Training: Practitioner is Certified and Board Certified as well as trained in numerous Energy Healing and Transformational Modalities Practitioner is also highly trained as a Success Coach, Relationship Expert with advanced training in NLP and Hypnosis, Conflict Resolution Techniques. (See About Me Education, Certifications and Client Testimonials.)

    

3. Outside Doctor/PatientConventional Psychological/Medical Services: Client understands that although Practitioner has been educated and trained in traditional secular psychological and behavioral sciences with a Doctorate in Clinical Psychology, he does not practice as a State Licensed Clinical Psychologist or Conventional Secular Mental Health / Medical Practitioner.

    

4. Scope of Practice: Practitioner does not claim to diagnose, treat or promise to cure any diagnosed pathology, physical, mental and emotional disease or illness that constitutes the conventional practice of medicine and psychology. Practitioner’s goal is to provide services as a complement to the traditional practice of medicine and mental health and provide coaching and relationship skills to clients to enhance all aspects of their life.

    

5. Records and Confidentiality – Client Protection: Client understands and agrees that if he/she chooses to be seen by Practitioner as a Pastoral Individual Relationship Counselor, that all Client’s records provided to or maintained by Practitioner are privileged ministerial communications and not medical records.

    

5. Non-Disclosure Policy And Exception: Client and Practitioner agree that all records between client and Practitioner may not in any case be released as medical records and that all information and communication shared between Client and Practitioner in Private are not subject to be released to any third party or Court of Law. The only exception is in accordance with Practitioner’s own policy wherein proper reporting may be made in the event any person is at risk of harm, or has been harmed, or as may be required in the jurisdiction where services are provided subject to the laws of reporting self/other harm.

    

6. AIWP Miracles Ministry: Client understands that all services are under the auspices of and sponsorship of The Association for Integration of the Whole Person (AIWP) Miracles Ministry, which is a federally recognized 501(c)(3) a non profit, non denominational, religious/spiritual organization Tax ID is 95-3455451 unless otherwise designated. Client also understands that Practitioner is the Founder, Director, and Lead Counselor and Minister at AIWP/Miracles Ministry.

    

7. Client Is Free To Choose: Client also understands that he or she has the prerogative to opt out of faith based individual / relationship counseling under the auspices of AIWP Miracles Ministry and participate only with Practitioner as a Professional Life and Relationship Expert and Highly Trained Success Coach.

    

8. Independent Practitioner: Client understands that if he/she chooses to see Practitioner solely as a Life/Relationship Coach that the Practitioner is an Independent Consultant and is not a representative of AIWP Miracles Ministry.

    

9. Limited Confidentiality. If Client elects to be seen for coaching purposes only, client understands that all communication has limited confidentiality. Information will be considered

   confidential and will not be shared with anyone outside of the practice unless there is a lawful subpoena or written court order compelling testimony or required by agreement of future employment by all relevant parties with a signed authorization request for such disclosure.

    

10. Indemnification: If Client chooses to see Practitioner for Life/Relationship Success Coaching, AIWP and AIWP/Miracles Ministry do not have, incur or accept any responsibility or liability for Practitioner’s actions, suggestions, or services.

     

11. Client Responsibility: Client understands that if the/she has a diagnosed disease or condition or becomes aware of a suspected disease or mental health diagnosis or condition, it is Client’s sole responsibility to seek appropriate medical and psychological care in place of or as an adjunct to the services provided by the Practitioner.

     

12. Practitioner Indemnification: Client acknowledges that although Practitioner does his best to insure a meaningful and successful outcome of the assistance, Practitioner does not provide any guarantee or warranty as to the success of any suggestions, techniques, protocols, or practice. Client accordingly agrees to hold Practitioner, AIWP and AIWP/ Miracles Ministry harmless for any claim or action based on failure to achieve desired results, short of evidence of negligence or intentional wrongdoing of the Practitioner.

12. Keep An Open Mind: Client agrees that by signing this agreement he/she is willing to be open to using safe, gentle, non-invasive various forms of Relationship Healing and Integrated Energy Healing Techniques to overcome Mind, Body, Relationship and Mind, Body, Relationship and Spiritual blocks to Success in order to provide optimum stress reduction, healing and transformation.

     

13. Twenty Four Hour Notice: Client agrees to give a 48 hour and/or minimum 24 hour cancellation notice (preferably a 48 hour notice) for all missed appointments (this is much appreciated as I often schedule a week ahead of time and I would like to give others a chance to fill your slot if possible.) Client also agrees to pay for missed sessions prior to scheduling future sessions unless there is an agreement between Practitioner and Client.

     

14. Commitment To Sessions: Client agrees to honor commitment to keeping sessions and that if he/she purchases any number of sessions these sessions must be used within a year of the purchase date in order to keep them valid and not to have them forfeited.

     

15. Client also agrees for the purpose of this agreement to have read and fully understand all aspects of this agreement and has obtained all information client deems necessary to determine whether Practitioner is suitable for Client, considering Practioner’s education, experience, services to be provided.

     

16. Having read the above I consent to participate in Online tele-health therapy and/or coaching with practitioner Timothy J. Ryan, Ph.D, D.Div.