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Gestalt Wellness Institute

1. Practitioner Information

2. Credential Documents

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3. Practitioner Terms of Agreement (GWI-PTA-2026-001)

Gestalt Wellness Institute Southeast Asia, Inc.  · 
Practitioner Agreement

Practitioner Terms of Agreement

Website Registration and Telemental Health Platform Use

Reference No.: GWI-PTA-2026-001
Version: 01
Effective Date:  
Governance status: This version (v01) is circulated for
institutional review pending ratification by
Board Resolution GWI-BR-2026-007. Article 5 (Telemental Health
Platform Obligations) is referred to the Clinical Governance Committee
and Article 7 (Data Privacy and Confidentiality) is referred to the
Compliance & Risk Committee for review under SOP-BAU-4.12. See
Section 16.10 (Interim Ratification and Re-Consent Protocol) for how any
resulting amendment affects Practitioners who accept this version before
ratification.
Prepared By Reviewed / Noted By Approved By
Chief Business Administrator Clinical Governance Committee (Art. 5)
Compliance & Risk
Committee (Art. 7)
Board of Directors
per GWI-BR-2026-007 (pending)

Recitals

WHEREAS, Gestalt Wellness Institute Southeast Asia,
Inc. (“GWI“), a Philippine
multidisciplinary mental health institution with its principal office at
Room 515, Velez Medical Arts Building, Ramos, Cebu City, operates a
website at www.gestaltwellness.com and a telemental health platform
through which GWI Practitioners deliver, coordinate, and document
clinical and professional services to Clients;

WHEREAS, the individual identified in the Acceptance
and Signature section of this Agreement (“Practitioner“) is, or is applying to become, a GWI Practitioner under one of the
engagement types recognized in the GWI Practitioner Manual
(GWI-PRC-2026-001), and wishes to register a Practitioner Account and
access the Website and Telemental Health Platform in that capacity;

WHEREAS, GWI is willing to grant such access subject to
the Practitioner’s agreement to the terms and conditions set out below,
which govern the Practitioner’s registration, conduct, and use of the
Website and Telemental Health Platform, separately from and in addition
to the contract governing the Practitioner’s substantive engagement with
GWI;

NOW, THEREFORE, in consideration of the mutual
covenants set forth herein, the Parties agree as follows:

Definitions

  1. “Agreement” means this Practitioner
    Terms of Agreement, including its Recitals, and any Annexes referenced
    herein.
  2. “Approved Platform” or
    “Telemental Health Platform” means
    the encrypted video, audio, or text-based platform(s) designated by
    GWI, from time to time, as approved for the delivery of clinical or
    professional services at a distance. Consumer messaging applications
    (e.g., Messenger, Viber, WhatsApp) are never Approved Platforms for
    clinical sessions.
  3. “Client” or
    “Service User” means an individual,
    family, or organization receiving clinical, assessment, training, or
    other professional services from GWI through the Practitioner.
  4. “Clinical Systems” means GWI’s
    psychological assessment workflows, scoring and interpretation
    protocols, case conceptualization frameworks, Gestalt-based
    therapeutic models, training curricula, documentation systems,
    electronic record structures, and other proprietary
    clinical-administrative processes made available to the Practitioner
    through the Platform or otherwise.
  5. “Engagement Contract” means the
    separate written contract governing the Practitioner’s substantive
    relationship with GWI, corresponding to the Practitioner’s Engagement
    Type under Chapter 2 of the Practitioner Manual — namely, an
    Employment Contract, Retainer Agreement, Service Agreement (Visiting
    Specialist), Clinical Mentoring and Residency Agreement (CMRA), or
    Consultancy Agreement, as applicable.
  6. “Personal Data” and
    “Sensitive Personal Information” have
    the meanings given under Republic Act No. 10173 (Data Privacy Act of
    2012).
  7. “Platform” means, collectively, the
    Website and the Telemental Health Platform, including all associated
    scheduling, billing, documentation, and communication modules operated
    or authorized by GWI.
  8. “Practitioner” means the licensed
    mental health, allied health, or clinical professional who registers a
    Practitioner Account under this Agreement, in any Engagement Type
    recognized by GWI.
  9. “Practitioner Account” means the
    individual login credentials and associated profile issued to the
    Practitioner for access to the Platform.
  10. “Website” means
    www.gestaltwellness.com and any GWI-operated subdomain, practitioner
    portal, or client-facing digital property.

Article 1 — Eligibility and Registration

1.1 Eligibility Requirements

To register a Practitioner Account, the applicant must: (a) hold a
current, valid license issued by the Professional Regulation Commission
(PRC), or hold applicable medical licensure, in good standing and
without unresolved disciplinary action affecting the license; (b) be
practicing within the scope authorized by that license, as further
defined in Article 3; and (c) satisfy the credentialing requirements of
SOP-PSU-5.1 (Practitioner Onboarding and Credentialing) and Chapter 2 of
the Practitioner Manual applicable to the Practitioner’s Engagement
Type.

1.2 Application and Credential Submission

The Practitioner shall submit, through the Website or as otherwise
directed by GWI: current PRC license and Certificate of Registration;
current Continuing Professional Development (CPD) record; relevant
specialization or competency documentation where applicable; and such
other documents as the Chief of Professional Services (CPS)/PSU Head or
Chief Business Administrator may reasonably require.

1.3 Verification and Activation

A Practitioner Account is provisional until GWI completes license
verification and scope review under SOP-PSU-5.1. GWI may activate,
delay, or decline activation of any Practitioner Account in its
reasonable discretion, including where credentials cannot be verified,
where the license is not in good standing, or where the applicant’s
scope of practice does not match the services to be offered through the
Platform.

1.4 Accuracy and Duty to Update

The Practitioner warrants that all information submitted in connection
with registration is true, accurate, and complete, and undertakes to
promptly update such information — including license renewal, CPD
compliance, specialty certifications, and any change in license status —
within the timeframes specified in the Practitioner Manual (Section 2.4)
and, in any event, within thirty (30) calendar days of the relevant
change.

1.5 Right to Suspend Pending Verification

GWI may suspend Platform access at any time pending verification of any
credential, or upon reasonable indication that a credential has lapsed,
been suspended, or is under investigation, without such suspension
constituting a breach of this Agreement.

1.6 Onboarding as a Condition of Activation

As a condition precedent to activation of the Practitioner Account and
the grant of Platform access, the Practitioner shall attend and complete
the GWI onboarding required under SOP-PSU-5.1, conducted either onsite
or remotely via an Approved Platform for video conference. GWI activates
the Practitioner Account only after the Practitioner has completed
onboarding and satisfied the verification and scope review under Section
1.3.

Article 2 — Relationship to Engagement Contract

2.1 Scope of This Agreement

This Agreement governs the Practitioner’s registration for, access to,
and use of the Website and Telemental Health Platform. It does not, by
itself, establish, define, or modify the Practitioner’s employment
status, scope of engagement, compensation, or term of service with GWI.

2.2 Engagement Contract Controls

The Practitioner’s substantive relationship with GWI — including
compensation, benefits (if any), term, and the specific clinical or
professional services the Practitioner is authorized to render — is
governed exclusively by the applicable Engagement Contract. Where the
Practitioner has not yet executed an Engagement Contract, registration
of a Practitioner Account does not itself create such a relationship,
and Platform access granted under this Agreement is limited to
activities reasonably necessary to complete onboarding.

2.3 Order of Precedence

In the event of any direct conflict between this Agreement and the
Practitioner’s Engagement Contract on a matter within the Engagement
Contract’s subject matter (compensation, term, employment status, or
clinical scope), the Engagement Contract controls. On all matters
concerning use of the Website and Telemental Health Platform, this
Agreement controls.

Article 3 — Professional Standards and Scope of Practice

3.1 Practice Within Scope

The Practitioner shall practice strictly within the scope of practice
defined by their PRC license (or other applicable licensure) and the
governing Republic Act for their profession, consistent with Chapter 3
of the Practitioner Manual. The Practitioner shall not use the Platform
to offer, advertise, or deliver any service outside that scope.

3.2 Compliance with Institutional Standards

The Practitioner shall comply with the Practitioner Manual
(GWI-PRC-2026-001), the applicable provisions of the Clinic Operations
Manual (GWI-SOP-PSU-2026-001), the GWI Code of Ethics, and all
applicable PRC board resolutions and codes of ethics, each as amended
from time to time and as made available to the Practitioner.

3.3 License and Credential Maintenance

The Practitioner is solely responsible for maintaining their own license
and credentials in good standing, including timely renewal and CPD
compliance under RA 10912, and shall notify the CPS/PSU Head immediately
of any complaint, investigation, disciplinary matter, or temporary
clinical incapacity affecting their ability to practice.

Article 4 — Practitioner Account and Platform Access

4.1 Individual, Non-Shared Credentials

The Practitioner Account is personal to the Practitioner. No shared
accounts or shared credentials are permitted for any system containing
Client information. The Practitioner shall not permit any other person
to access the Platform using the Practitioner’s credentials.

4.2 Security Requirements

The Practitioner shall maintain a strong password meeting GWI’s
institutional password protocol and shall enable two-factor
authentication where available. The Practitioner is responsible for all
activity occurring under their Practitioner Account, except activity
resulting from GWI’s own security failure.

4.3 Notice of Unauthorized Access

The Practitioner shall notify the Chief Business Administrator
immediately, and in no event later than twenty-four (24) hours, upon
becoming aware of any actual or suspected unauthorized access to, or
compromise of, the Practitioner Account.

4.4 Platform Availability and Modification

GWI may modify, update, or temporarily suspend features of the Platform
for maintenance, security, or operational reasons, and shall provide
reasonable advance notice of scheduled downtime where practicable. GWI
does not warrant uninterrupted or error-free Platform operation.

Article 5 — Telemental Health Platform Obligations

This Article applies to any Practitioner authorized to deliver services
via the Telemental Health Platform.

5.1 Approved Platforms Only

The Practitioner shall conduct clinical telehealth sessions solely
through GWI-approved encrypted platforms. Consumer messaging
applications are never used for clinical sessions, consistent with the
telehealth service delivery protocols of the Clinic Operations Manual
(GWI-SOP-PSU-2026-001).

5.2 Suitability Screening and Informed Consent

Before delivering telehealth services to a Client, the Practitioner
shall complete the Telehealth Suitability Screening (Form A.15) and
obtain the Client’s signed Telehealth Informed Consent Addendum (Form
A.2b), in addition to the standard Informed Consent and Treatment
Agreement, prior to commencing services.

5.3 Geographic and Jurisdictional Limits

Telehealth practice through the Platform is limited to Clients
physically located in the Philippines, unless: (a) the Practitioner
holds applicable licensure or temporary practice authorization in the
Client’s jurisdiction; (b) the engagement is documented as a discrete
consultation rather than ongoing care; or (c) a specific institutional
arrangement has been approved in writing by the Chief of Clinic.

5.4 Recording Prohibition

Neither the Practitioner nor the Client may record any session without
explicit prior written consent from both parties, consistent with the
Telehealth Informed Consent Addendum.

5.5 Session Interruption and Emergency Protocol

The Practitioner shall follow GWI’s session interruption protocol and
emergency response procedure for telehealth, as set out in the Clinic
Operations Manual (GWI-SOP-PSU-2026-001) and the Emergency Response
Manual (GWI-ERM-2026-001), in the event of a technical disruption or a
clinical emergency arising during a remote session, including verifying
the Client’s location at the start of each session and maintaining a
current local emergency contact on file.

5.6 Asynchronous Communication

Asynchronous messaging through the Platform may be used only as an
adjunct to live sessions for non-urgent clinical content. It shall never
be used for crisis communication; Clients in crisis are directed to call
the clinic, present in person, or contact emergency services. The
Practitioner is not obligated to provide 24/7 asynchronous response
coverage and shall state their response window in the Client’s treatment
agreement.

5.7 Documentation

All telehealth sessions shall be documented to the same standard as
in-person sessions, plus modality, platform name, the Client’s confirmed
location, identity of any other person present, and any technical
interruptions, consistent with SOP-PSU-2.2 and SOP-PSU-3.

Article 6 — Acceptable Use of Website and Platform

The Practitioner shall not, in connection with the Platform:

  • Access, or attempt to access, any account, data, or system feature not
    authorized for the Practitioner’s role;
  • Scrape, harvest, reverse-engineer, or extract Platform data or source
    code, except as GWI expressly permits;
  • Circumvent, disable, or interfere with any security, authentication,
    or access-control feature of the Platform;
  • Use the Platform to offer or deliver services outside the
    Practitioner’s verified scope of practice or authorized Engagement
    Type;
  • Transmit, upload, or store Client data using personal email, consumer
    messaging applications, or personal cloud storage, consistent with
    GWI’s IT security protocols under the Business Operations Manual
    (GWI-SOP-BAU-2026-001);
  • Use any AI tool in connection with Platform-based clinical
    documentation or client-adjacent work unless that tool appears on
    GWI’s Permitted AI Tools Register, consistent with GWI’s AI governance
    policy;
  • Use the Platform to solicit Clients for services outside of GWI, or to
    advertise a competing practice; or
  • Upload, transmit, or store any content that is unlawful, infringing,
    or that misrepresents the Practitioner’s credentials, licensure, or
    scope of practice.

Article 7 — Data Privacy and Confidentiality

7.1 Data Privacy Act Compliance

The Parties acknowledge that Client data processed through the Platform,
including health and psychological information, constitutes Sensitive
Personal Information under Republic Act No. 10173. The Practitioner
shall: process Personal Data only for legitimate purposes connected to
authorized services; implement reasonable safeguards on any device used
to access the Platform; ensure that any staff or trainee under the
Practitioner’s supervision with incidental access is bound by equivalent
confidentiality obligations; and notify GWI’s Data Protection Officer
without undue delay, and in no event later than twenty-four (24) hours,
upon becoming aware of any actual or suspected personal data breach
involving Client data accessed through the Platform.

7.2 Storage on Approved Systems Only

Client records, session notes, assessment data, and related Sensitive
Personal Information shall be created, stored, and transmitted only
through GWI-approved systems. The Practitioner shall not maintain
independent, unauthorized copies of Client records outside the Platform.

7.3 Confidentiality of GWI Business Information

The Practitioner shall treat as confidential all non-public GWI business
information encountered through the Platform, including administrative
data, pricing, and other practitioners’ personnel information, and shall
not disclose such information to any third party without GWI’s prior
written consent. This obligation survives termination of this Agreement
for five (5) years. Nothing in this Article limits or modifies the
Practitioner’s own confidentiality obligations to Clients, which are
governed by RA 11036, the applicable PRC code of ethics, and the
Client’s Informed Consent and Treatment Agreement, nor does it impose on
GWI any confidentiality obligation inconsistent with mandatory reporting
or legal disclosure requirements.

7.4 Mandatory Reporting Acknowledgment

The Parties acknowledge that the Practitioner, as a licensed
professional, is bound by mandatory reporting obligations under RA 9262,
RA 7610, RA 8505, RA 11313, and RA 11930. Nothing in this Agreement
limits, waives, or modifies those obligations, and compliance with
mandatory reporting shall not constitute a breach of this Agreement or
of any confidentiality obligation hereunder.

7.5 Data on Deactivation

Upon deactivation of the Practitioner Account for any reason, Client
records created through the Platform remain the property of GWI as
custodian of the clinical record and are retained per GWI’s data
retention schedule; the Practitioner’s own access is revoked, but the
Practitioner’s documentation obligations for services already rendered
survive deactivation.

Article 8 — Intellectual Property

8.1 Clinical Systems

GWI’s Clinical Systems constitute trade secrets and proprietary
intellectual property of GWI. The Practitioner shall: maintain strict
confidentiality regarding all Clinical Systems accessed through the
Platform; not reproduce, replicate, adapt, or incorporate any element of
the Clinical Systems into the Practitioner’s own materials, products, or
methods without GWI’s prior written consent; and not disclose Clinical
Systems information to any third party, competing institution, or
prospective employer. This obligation survives termination of this
Agreement for five (5) years.

8.2 Website and Platform Content

All Website and Platform content, including branding, templates, design
elements, and GWI-authored materials made available to the Practitioner,
remain the exclusive property of GWI. The Practitioner receives a
limited, non-transferable license to use such content solely in
connection with authorized GWI services, which terminates automatically
upon deactivation of the Practitioner Account.

Article 9 — Fees, Billing, and Platform Administration

9.1 Professional Fees

The Practitioner’s professional fees or compensation for services
rendered are governed exclusively by the applicable Engagement Contract
and, where applicable, GWI’s current fee schedule. Nothing in this
Agreement sets or alters the Practitioner’s compensation.

9.2 Platform-Facilitated Billing

Where the Platform is used to schedule sessions or process Client
payments on the Practitioner’s behalf, GWI shall remit the
Practitioner’s net professional fees in accordance with the payment
terms and any documented processing or administrative charges specified
in the applicable Engagement Contract or its Annexes. This Agreement
does not itself establish a fee-sharing or commission structure.

9.3 Taxes

Where the Practitioner is engaged other than as an Employed
Practitioner, the Practitioner is solely responsible for applicable
taxes on fees received, without prejudice to GWI’s withholding
obligations under applicable BIR regulations.

Article 10 — Engagement Status

This Article applies to Practitioners engaged as Retainer Practitioners,
Visiting Specialists, Consultants, or CMRA Residents. The Parties
expressly agree that this Agreement, standing alone, does not create an
employer-employee relationship, and that the Practitioner’s status as an
independent contractor or resident (as applicable) is established by the
Engagement Contract, not by this Agreement. For Employed Practitioners,
the employer-employee relationship and all attendant obligations are
governed exclusively by the GWI HR Manual and the Practitioner’s
Employment Contract; nothing in this Agreement alters, waives, or is
intended to alter that relationship.

The existence of an employer-employee relationship is a legal
determination under the four-fold test applied by Philippine labor
authorities and is not conclusively established by contract label alone.

Article 11 — Limitation of Liability

To the maximum extent permitted by applicable law, GWI’s total aggregate
liability to the Practitioner for all claims arising out of or related
to this Agreement, whether in contract, tort, or otherwise, shall not
exceed the total Platform-related fees, if any, actually paid by the
Practitioner to GWI under this Agreement during the twelve (12) months
immediately preceding the event giving rise to the claim. GWI shall not
be liable for indirect, incidental, special, consequential, or exemplary
damages, including loss of revenue or business interruption, arising
from Platform downtime or unavailability. This limitation does not apply
to GWI’s liability for its own gross negligence, fraud, or bad faith,
which cannot be excluded under Article 1172 of the Civil Code.

Article 12 — Indemnification

The Practitioner shall defend, indemnify, and hold harmless GWI, its
officers, directors, employees, and agents from claims, damages,
liabilities, costs, and reasonable expenses (including attorney’s fees)
arising out of: (a) the Practitioner’s material breach of this
Agreement; (b) the Practitioner’s negligence or willful misconduct in
using the Platform; (c) the Practitioner’s unauthorized use or
misrepresentation of GWI content or credentials; or (d) third-party
claims caused by the Practitioner’s acts or omissions in using the
Platform. This indemnification does not extend to claims arising from
GWI’s own gross negligence or bad faith, and is proportionate to the
Practitioner’s actual contribution to the cause of loss.

Article 13 — Non-Solicitation of GWI Clients

During the term of this Agreement and for twelve (12) months following
its termination or expiration, the Practitioner shall not directly
solicit or provide, for commercial gain outside of GWI, the same type of
professional services to any Client who was actively receiving services
from GWI in the twelve (12) months prior to termination and with whom
the Practitioner had direct professional contact through the Platform.
This restriction is limited to Cebu City and other localities where GWI
actively operates, to the specific service types the Practitioner
provided at GWI, and to the twelve (12)-month period stated above. It
does not prohibit the Practitioner from accepting unsolicited contact
from former Clients, practicing their licensed profession independently,
serving any person who was not a GWI Client during the relevant period,
or making a referral required by professional ethics. GWI acknowledges
that continuity of mental health care is a clinical ethics priority, and
this clause shall not override a Client’s right to access care or the
Practitioner’s professional ethics obligations.

Article 14 — Suspension and Termination

14.1 Deactivation for Convenience

GWI may deactivate the Practitioner Account for operational or
administrative reasons unrelated to misconduct upon fifteen (15)
calendar days’ written notice, without affecting the Practitioner’s
rights under any separate Engagement Contract then in force.

14.2 Deactivation for Cause

GWI may suspend or deactivate the Practitioner Account immediately, with
contemporaneous written notice, where the Practitioner: (a) allows their
PRC license to lapse, or the license is suspended or revoked; (b) fails
a required credentialing or scope review; (c) materially breaches this
Agreement, including the Acceptable Use provisions of Article 6, and
fails to cure a curable breach within fifteen (15) calendar days of
written notice; (d) causes or contributes to a data privacy or security
incident through misuse of the Platform; or (e) violates applicable law
or professional regulatory standards in a manner materially affecting
Platform use. GWI shall not invoke this Section for minor or technical
breaches that do not materially affect Client safety, data security, or
institutional standing.

14.3 Automatic Deactivation on End of Engagement

Termination or expiration of the Practitioner’s Engagement Contract
automatically terminates this Agreement and deactivates the Practitioner
Account. Termination of this Agreement alone does not terminate the
Engagement Contract, which is governed by its own terms.

14.4 Effects of Termination

Upon termination or deactivation for any reason: (a) the Practitioner’s
access to the Platform is revoked; (b) the Practitioner shall complete
documentation for services already rendered within ten (10) calendar
days, or such shorter period as patient safety requires; (c) the
Practitioner shall cooperate in the continuity-of-care handover of any
active Clients per the Clinic Operations Manual; (d) each Party shall
return or, upon written request, confirm destruction of any confidential
materials in its possession belonging to the other, within ten (10)
calendar days; and (e) Articles 7 (Data Privacy and Confidentiality), 8
(Intellectual Property), 11 (Limitation of Liability), 12
(Indemnification), 13 (Non-Solicitation), and 16.1 (Dispute Resolution)
survive termination as stated therein.

Article 15 — Force Majeure

Neither Party is liable for failure or delay in performance under this
Agreement caused by circumstances beyond its reasonable control,
including natural disasters, pandemic or epidemic declarations,
government quarantine measures, civil unrest, or interruption of
essential utilities or internet infrastructure affecting the Platform.
The affected Party shall notify the other in writing within five (5)
calendar days of onset. If a Force Majeure Event affecting Platform
availability continues beyond thirty (30) calendar days, the
Practitioner may request activation of GWI’s documented
backup/continuity protocol for ongoing clinical services.

Article 16 — General Provisions

16.1 Dispute Resolution

Any dispute arising out of or relating to this Agreement shall first be
addressed through written notification and good-faith negotiation within
fifteen (15) calendar days. If unresolved, the Parties shall submit to
mediation under Republic Act No. 9285 (Alternative Dispute Resolution
Act of 2004) in Cebu City. If mediation fails, disputes shall be
resolved by the appropriate courts of Cebu City, Philippines, to the
exclusion of all other courts, under Philippine law.

16.2 Amendment

GWI may update this Agreement from time to time to reflect changes in
law, regulation, or Platform functionality. Material changes shall be
notified to the Practitioner through the Platform or by email at least
fifteen (15) calendar days before taking effect; continued use of the
Platform after that date constitutes acceptance. Any other amendment
must be in writing and signed by GWI’s authorized representative.

16.3 Entire Agreement

This Agreement constitutes the entire agreement between the Parties
regarding Website and Telemental Health Platform use and supersedes all
prior understandings on that subject. It does not supersede, and shall
be read together with, the Practitioner’s Engagement Contract and the
Practitioner Manual, which continue to govern the matters within their
respective scope per Article 2.

16.4 Severability

If any provision of this Agreement is held invalid, illegal, or
unenforceable, it shall be modified to the minimum extent necessary to
be valid and enforceable, or severed if modification is not possible,
without affecting the remaining provisions.

16.5 Language

This Agreement is in English, the controlling language for all purposes.
Any translation is for reference only.

16.6 Governing Law

This Agreement is governed by and construed in accordance with the laws
of the Republic of the Philippines.

16.7 Waiver

No failure or delay by either Party in exercising any right under this
Agreement constitutes a waiver of that right.

16.8 Notices

Notices to GWI shall be sent in writing to the Chief Business
Administrator at GWI’s principal office (Room 515, Velez Medical Arts
Building, Ramos, Cebu City 6000) or to GWI’s official administrative
email address on record, with confirmation of receipt. Notices to the
Practitioner shall be sent to the email address and contact information
on file in the Practitioner Account.

16.9 Electronic Execution

The Practitioner acknowledges that this Agreement may be executed and
accepted electronically through the Website registration process, and
that such electronic acceptance is valid and binding under Republic Act
No. 8792 (Electronic Commerce Act of 2000). Where the Practitioner’s
Engagement Type requires a notarized Engagement Contract, that
requirement applies to the Engagement Contract and not to this
Agreement.

16.10 Interim Ratification and Re-Consent Protocol

The Practitioner acknowledges that this version (v01) of the Agreement
is circulated and made available for acceptance pending review by the
Clinical Governance Committee (Article 5) and the Compliance & Risk
Committee (Article 7), and pending ratification by the Board of
Directors under Board Resolution GWI-BR-2026-007. Acceptance of this
version is effective and binding upon execution, and Platform access
granted on that basis is valid pending the outcome of that review. If
committee review results in a material amendment to Article 5 or Article
7 prior to or upon Board ratification, GWI shall notify all
Practitioners who accepted v01 through the Website or by email, and
shall require each such Practitioner to affirmatively re-accept the
amended version through the Practitioner Account before continued access
to the Telemental Health Platform. A Practitioner who does not re-accept
within thirty (30) calendar days of notice shall have Platform access
suspended under Article 14.1 until re-acceptance, without prejudice to
the Practitioner’s rights under any separate Engagement Contract then in
force. Amendments that are not material — clarifications, formatting, or
corrections that do not change the substantive obligations of Article 5
or Article 7 — follow the ordinary notice procedure of Section 16.2 and
do not require re-acceptance under this Section.

16.11 Term and Renewal

Without prejudice to earlier suspension, deactivation, or termination
under Article 14, this Agreement takes effect on the Effective Date (or,
if earlier, upon the Practitioner’s electronic acceptance and account
activation) and is valid for a term of one (1) year. It renews
automatically for successive one-year terms unless either Party gives
written notice of non-renewal at least thirty (30) calendar days before
the end of the then-current term. Upon each renewal, GWI may re-verify
the Practitioner’s PRC license and Continuing Professional Development
currency under Article 1. Termination or expiration of the
Practitioner’s Engagement Contract terminates this Agreement as provided
in Section 14.3, notwithstanding any unexpired term.

Acceptance and Signature

By checking the acceptance box and completing registration on the
Website, or by signing below, the Practitioner acknowledges having read
and understood this Agreement in its entirety, including its Recitals,
and voluntarily agrees to be bound by its terms.

Practitioner
Full Legal Name:
 
PRC License No. / Type:
 
Signature / Electronic
Acceptance:  
Date:
 
For Gestalt Wellness Institute Southeast Asia, Inc.
Name: Rennyvonne Fae V. Ledesma, RPsy
Designation: Chief
of Professional Services (CPS) / PSU Head
Signature:
 
Date:
 
Gestalt Wellness Institute Southeast Asia, Inc.  ·  Room 515,
Velez Medical Arts Building, Ramos, Cebu City 6000  ·  (032) 345
4610  ·  www.gestaltwellness.com
GWI-PTA-2026-001 v01 — Confidential draft for internal legal review ·
Pending ratification under Board Resolution GWI-BR-2026-007

Please scroll to the end of the Agreement above to enable acceptance below.

4. Consents & Attestations

Each item below is separate and required.

See our Privacy Policy. Data Protection Officer: privacy@gestaltwellness.com.

5. Signature

Choose how you wish to sign.

If you choose the wet-signature method and don't have the signed copy yet, you may submit now and your record will remain pending until the signed copy is received; or print the record first from the confirmation page.