Please Read Carefully

Thank you for your interest in receiving assistance from the below named Practitioner of Pastoral Science & Medicine.

The Practitioner is a member of the Pastoral Medical Association*(PMA) and is required to provide certain disclosures to you and to provide assistance only when the Practitioner and you have signed the Agreement below providing specific terms and conditions of your relationship as a Client of the Practitioner. This Agreement below meets these requirements.

In the Agreement below, your Practitioner is referred to as “Practitioner”; you are referred to as “Client”; the term “Party” refers to an indicated party to the Agreement; and the term “Parties” refers to your Practitioner and you jointly.

Please read this Agreement carefully and indicate your acceptance of its terms by signing in the form below. You will be emailed a copy of this signed form, as will your practitioner, if any.


Client Information
Street Address*
City, State, Zip*
Signature (type your name)*
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