The UCI Debriefing Disclosure Statement (hereinafter referred to as the “Statement”) is entered into immediately upon clicking “I Agree” and beginning any portion of the online clinical instrument process, between Blessing Ranch, Inc., dba Blessing Ranch Ministries (hereinafter referred to as the “Providers”) and you, the user of the Unhindered Clinical Instrument (hereinafter referred to as the “Client”), collectively referred to as the “Clients.” All Clients agree as follows:

Provider Names and Credentials:
The Client will meet with one of the following Providers throughout the clinical instrument process. The assigned Provider is subject to change based on scheduling criteria. Unless otherwise stated prior to the debriefing experience, the Provider will be randomly assigned. Please note: the Client may be paired with a third party contracted Provider subject to availability and scheduling. Moreover, if you have been asked to take the UCI by a third party (employer, counselor, etc.), then your debrief may take place with a trained third party provider.

Brian Stone: Ministry Leadership Coach, Reformed Church; Gottman Level 2 Relationship Certification; Faithwalking Coach; Coach using the Unhindered Model through BRM, UCI Debriefing Provider approved by BRM

Brandi Wilson: CaPP Institute Life Coach Certification; Coach using the Unhindered Model through BRM; UCI Debriefing Provider approved by BRM

Charity Byers, Ph.D.: (Counseling Psychology, University of Denver), Licensed Psychologist, PY 9195; Coach using the Unhindered Model through BRM; UCI Debriefing Provider approved by BRM

Hannah Lockaby: Coach using the Unhindered Model through BRM; UCI Debriefing Provider approved by BRM

Matthew Brown: Coach using the Unhindered Model through BRM; UCI Debriefing Provider approved by BRM
Business Address: 4905 Van Dyke Rd., Lutz, FL 33558
Business Phone: (970) 495-0920. Blessing Ranch Ministries does not provide 24-hour crisis support by phone. Phone calls will be returned at our earliest convenience. Note: Business phone may be different from your Provider’s phone number.

Business Email: info@blessingranch.org
Email is not considered a confidential form of communication and Blessing Ranch Ministries cannot ensure receipt in a timely manner; therefore, email should not be used to seek support in an emergency or crisis situation. Emails will be responded to at our earliest convenience.

Blessing Ranch Ministries provides debriefing services in accordance with the following guidelines:
Providing you with honor and respect is of primary importance. Therefore, the highest level of professional ethics will be adhered to.
The relationship between Provider and Client is professional. Any form of inappropriate behavior will not be tolerated by either the Providers or Client, resulting in immediate termination of services and reporting to the Blessing Ranch Ministries CEO and any appropriate certifying agency. Inappropriate behavior includes, but is not limited to, sexual contact, overreaching emotional engagement, or abuse of power or authority.
Our mission is to restore and renew Christian leaders for effective Kingdom service by providing services that minister to the core of the leader’s needs rather than just the symptoms. - Services integrate and blend traditional coaching practices with God’s Word and prioritize God’s will for your life.
Blessing Ranch Ministries’ Providers strictly adhere to ethical principles outlined by the ICF code of ethics for coaching found at ICF Code of Ethics - International Coaching Federation. - At your request, Blessing Ranch Ministries will provide more information about the methods of services, the techniques used, the duration of services, and the fee structure.

As a client, you have the right to:
Not be discriminated against, but be treated with honor, respect, and dignity.
Actively participate with your Provider in setting goals and creating a plan for your growth. - Include other people you think would be helpful in creating a plan for your care. - Receive services only if you consent by signing this Statement.

Terminate services at any time for any reason.
Refuse services unless you are court ordered or under other legal obligation to receive services and are informed of the consequences of your refusal.

Upon request, receive additional written information about Blessing Ranch Ministries’ services and providers.

Voice grievances about services provided at any time and without retaliation to: Department of Health Consumer Services Unit 4052
Bald Cypress Way Bin C-75, Tallahassee, FL 32399-3260,
Phone: 850-488-0796, E-mail: MQA.ConsumerServices@flhealth.gov.

Confidentiality: The debriefing relationship, as well as all information (documented or verbal) that the Client shares with the Provider as part of this professional relationship, is bound by the principles of confidentiality set forth in the ICF Code of Ethics. Generally, the information provided by and to you during the Debriefing service by Blessing Ranch Ministries will be held confidential and cannot be released without your consent. Blessing Ranch Ministries’ Providers adhere to a general right to privacy regarding Client information, including, but not limited to, personal information, financial information, and general health.

The Provider-Client relationship is not considered a legally binding relationship (like medical or legal professions) and thus, communications are not subject to the protection of any legally recognized privilege. Clients have a legal right to privacy, but no legal right to confidentiality.

Client is advised that exceptions exist to the ICF Code of Ethics. General exceptions include, but are not limited to, a threat of serious harm to oneself or others, including cases of child abuse, homicide, and grave disability; under a court order; or in response to any legal action initiated by the Client against Blessing Ranch Ministries. If a legal exception arises during treatment, if feasible, the Client will be notified accordingly.
Confidential information does not include information that: (a) was in the Provider’s possession prior to its being furnished by the Client; (b) is generally known to the public or in the Client’s industry; (c) is obtained by the Provider from a third party, without breach of any obligation to the Client; (d) is independently developed by the Provider without use of or reference to the Client’s confidential information; or (e) the Provider is required by statute, lawfully issued subpoena, or by court order to disclose; (f) is disclosed to the Provider and as a result of such disclosure the Provider reasonably believes there to be an imminent risk of danger or harm to the Client or others; and (g) involves illegal activity. The Client also acknowledges his or her obligation to raise any confidentiality questions or concerns with the Provider in a timely manner.

Emergency/Crisis: Blessing Ranch Ministries does not have a 24-hour crisis line and in the event of an emergency, call 911 or go to the nearest emergency room. Blessing Ranch Ministries is not equipped with necessary precautionary safety measures for those with active suicidal thoughts, tendencies, or actions, or any measure of self-harm. Clients in our services must not be an active physical threat to themselves or someone else.If you are in an emergency situation or are an imminent physical threat to yourself or someone else, please contact 911 or go to your local Emergency Room immediately. Blessing Ranch Ministries is not a treatment facility for substance abuse or recovery. Clients must be free of substance abuse for thirty days prior to services to have the clear mind needed for benefit.

Cancellations/Missed Appointments/Termination:
Any appointment changes or cancellations must be made at least 24 hours in advance of the scheduled appointment day/time. If more than two appointments are missed or rescheduled with less than 24 hours notice, then the Client may be asked to file a credit card authorization form through Blessing Ranch Ministries and be charged at the current rate for a coaching session in order to resume services.
Your appointment can be modified or canceled by emailing info@blessingranch.org or by emailing your Debriefer directly within the permissible timeframe.

Payment:
Payment is expected before the time of service. Unless otherwise arranged, payments will be made via credit card and processed using a secure payment portal. Credit card information may be stored by the secure payment portal upon the first transaction for future use. Blessing Ranch Ministries attests to security compliance of the payment portal.

Training of Providers:
The practice of life, executive, or relationship coaching is unregulated by governmental agencies. Every Blessing Ranch Ministries Provider has received training through an external organization and has been rigorously screened by and further equipped by Blessing Ranch Ministries’ clinical staff as a Coach. The Client Coach relationship is not to be construed as psychotherapy, psychological counseling or any type of therapy, substance abuse treatment, professional advice by a medical, legal, or other qualified professional, nor is it a substitute for these services. It is the Client’s responsibility to seek such services as needed. Coaching is the future-focused practice of partnering with clients in a thought-provoking and creative process that inspires them to maximize their personal and professional potential. Professional coaching focuses on setting goals, creating outcomes, and managing personal change.
Limited Liability:
Unless expressly provided in this Agreement, the Provider makes no guarantees, representations or warranties of any kind or nature, express or implied with respect to the services negotiated, agreed upon and rendered. In no event shall the Provider be liable to the Client for any indirect, consequential, or special damages. Notwithstanding any damages that the Client may incur, the Provider’s entire liability under this Agreement, and the Client’s exclusive remedy, shall be limited to the amount actually paid by the Client to Blessing Ranch Ministries for all debriefing services rendered through and including the termination date.
Follow-Up: Blessing Ranch Ministries may contact you following the termination of services to gather information needed for follow-up, program evaluation, and collection of unpaid debts.

Destruction of Records: Records from services by Blessing Ranch Ministries may be destroyed if no further treatment is rendered after seven years from the date of termination.
Information for Telehealth Treatment
Telehealth treatment is live two-way communication using electronic/internet/data transmission to treat the needs of a client. Telehealth treatment allows the Provider and Client to meet outside of a physical office setting and may or may not include virtual face-to-face interactions. Telehealth treatment affords the Client the ability to be debriefed from any location at any time. Telehealth services may or may not be used during the Client’s treatment, however, the Client understands and agrees to the following:
The option to withhold or withdraw consent to Telehealth treatment at any time unless under a court order or other legal obligation to receive services and having been informed of the consequences of refusal remains in effect.
All policies included within the above Statement apply to Telehealth services, including but not limited to scheduling, missed appointments, cancellation, and payment requirements. - The laws that protect privacy in a Coach-Client relationship apply to Telehealth services. - No information obtained in Telehealth treatment, including but not limited to identifying information or treatment notes, will be disclosed to a third party without the Client’s written consent. - Telehealth services will not be audio or video recorded, in whole or in part, without the Client’s written consent.
Blessing Ranch Ministries and the Provider will use reasonably effective measures to ensure the security of all Telehealth communication.
The use of electronic/internet/data transmission is not 100% guaranteed to be secure. There are no universal protocols or protective standards in Telehealth treatment.

The Client will hold Blessing Ranch Ministries and its employees harmless and free from liability in the event that security is breached and/or private information is leaked due to the risks, complexities, and abnormalities involved with technology used in Telehealth services.
Limitations to Telehealth treatment exist, including but not limited to technological interruptions and/or difficulties, unauthorized access, and the potential loss of therapy cues due to the lack of in person contact.
The Coach reserves the right to contact emergency services and/or the Client’s emergency contact if an emergency arises during Telehealth treatment.

Telehealth treatment is not appropriate if the Client is experiencing a life-threatening crisis or having thoughts or intentions of harming oneself or others. The Client is required to contact appropriate emergency services in lieu of Blessing Ranch Ministries or the Coach if one or more of these scenarios arise.
If the Client wishes to revoke Telehealth consent, it must be documented in writing and submitted to Blessing Ranch Ministries.
I have read the preceding information, it has also been provided verbally, and I understand my rights as a client to both Debriefing and Telehealth Services.

Clients agree to all terms and conditions of this Statement set forth above as demonstrated by clicking “I Agree.”