Questionnaire & Consent Form

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Name* This field is required.Please enter your name.

First Name

Last Name

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Email* This field is required.Please enter your email address.

example@example.com

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Address* This field is required.Please enter your current address.

Street Address

Street Address Line 2

City

State

Zip Code

Country

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Your Phone Number* This field is required.Please enter the best phone number for you.

Area Code

Phone Number

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Birth Date* This field is required.

Birth Date

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Preferred Pronouns

She/Her/Hers

They/Their

He/Him/His

Other

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Emergency Contact's Name* This field is required.Please enter the name of your emergency contact.

First Name

Last Name

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Emergency Contact's Phone Number* This field is required.Please enter your emergency contact's phone number.

Area Code

Phone Number

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What are your interest(s) in working with Dr. Michaelene?* This field is required.

Psychedelic Integration of a previous experience

Microdosing

Sacred Plant Medicine Immersion

Sacred Plant Medicine Immersion Training for Therapists

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Have you ever been in therapy/counseling before?* This field is required.

YESNO

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Are you currently in therapy/counseling?* This field is required.

YESNO

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Prior to the session please share a bit about yourself, guided by the following outline. The purpose of writing this is to get your internal process started, to help you clarify your intentions, and to provide me with some useful background. This form is encrypted according to HIPPA law.

In responding to these questions, start by giving brief answers, then notice which area most strongly engages your attention and expand your answers in that area. Plan on writing a total of between 30 - 90 minutes. Please type your responses at least 3 days before your appointment and select SUBMIT. They will be sent to me directly.

Not all questions will apply. Please do your best to answer all those that do.

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Birth: Where and when were you born? Based on what you later learned, was your birth difficult in any way? Did you have any health problems as a newborn? Please answer as best as you can.

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Birth: What sisters and brothers did you have at the time of birth, and what siblings came later? Please answer as best as you can.

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Childhood: Tell about any pattern of behaviors, severe illnesses, accidents, traumas, or other childhood difficulties. What went wrong? In what circumstances were you shamed or punished?Please answer as best as you can.

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Family: Mother - During the time you were growing up, what relationship did you have with your mother? Describe her physical, mental, and emotional characteristics as a mother, wife, and person. Include one or more anecdotes that illustrate how she affected your life. What is her age now (or, if no longer living, at time of death)? Please answer as best as you can.

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Family: Father - During the time you were growing up, what relationship did you have with your father? Describe his physical, mental, and emotional characteristics as a father, husband, and person. Include one or more anecdotes that illustrate how he affected your life. What is his age now (or, if no longer living, at time of death)? Please answer as best as you can.

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Family: Any other older relatives or others who lived with you or were frequently present and helped with your care, and brothers and sisters.Please answer as best as you can.

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Family: What was your role in the family (for example, mommy's favorite, odd one out, little sister or brother, trouble-maker, example to others)?Please answer as best as you can.

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Education: Describe briefly your schooling, including higher education. What were your typical relations with classmates and with teachers? In what ways did you take part in extracurricular activities? What was the attitude of your parents toward your education? To what extent did you feel like a success in school? Please answer as best as you can.

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Education: Apart from formal education, in what ways did you learn the most? What other places, people, and activities taught you most about life and the world?Please answer as best as you can.

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Religion/Spiritual Life: Was your family associated with one or more religions while you were growing up? If so, which ones? To what extent were they active? What effect did religion have on your development?Please answer as best as you can.

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Religion/Spiritual Life: Describe your religious beliefs, including concepts of God, death, heaven and hell, ethics, and observances. Please answer as best as you can.

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Religion/Spiritual Life: Have you had any mystical experiences? If so, even if they were impossible to describe, what could you say at least to point someone else in the direction of what you experienced?Please answer as best as you can.

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Career: Describe the main jobs that you have held. What are your ambitions in your profession, business, or line of work? What have been your major frustrations? Your major satisfactions and successes? Please answer as best as you can.

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Military History: If you have served or are serving in the military, what were your reasons for entering? At what age did you serve? As in the questions about career, what were your major satisfactions and frustrations? Please answer as best as you can.

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Legal History: Have you ever been charged with a crime? If so, how was the case resolved? What are your attitudes toward the police and the court system? Have you been involved in a contested divorce? In any other kind of lawsuit, including any arising out of an accident, a business dispute, or malpractice? Describe the circumstances.Please answer as best as you can.

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Habits: With regard to the following substances, describe your pattern of use (if any), any problems associated with these patterns, the effect on you, including any unusual experiences: Tobacco; alcoholPlease answer as best as you can.

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Sex and Marriage: In what ways did you observe or become involved in sexual behavior as a child, including any abuse.Please answer as best as you can.

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Sex and Marriage: From whom, and in what ways, did you learn about sex? What attitudes did you learn?Please answer as best as you can.

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Sex and Marriage: If you are married or living together, describe your courtship, the relative age of your partner, and (in the case of marriage) the reasons for and circumstances of your wedding, including any opposition to it and conflict surrounding it.Please answer as best as you can.

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Sex and Marriage: Describe your "significant others," including spouse and lovers, and your relationship with each of them, past and present. What are the major areas of compatibility and challenge?Please answer as best as you can.

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Sex and Marriage: Describe attitudes toward having children. If you have any, describe their ages, character, and your feelings about them.Please answer as best as you can.

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Health: Discuss any chronic or hereditary illnesses in your family.Please answer as best as you can.

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Health: Describe your major illnesses and their effects on you.Please answer as best as you can.

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Health: Sketch your major fears and phobias, including any knowledge you have about their sources.Please answer as best as you can.

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Health: List any current medications and the reason you are taking it, whether for physical illness or psychiatric condition (including depression).Please answer as best as you can.

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Self-Image: How do you see yourself as a person? To what extent do you like yourself?Please answer as best as you can.

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Self-Image: What do you not like about yourself?Please answer as best as you can.

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Self-Image: Describe your main strengths and inadequacies.Please answer as best as you can.

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Self-Image: What are you guilty about? What are you ashamed of?Please answer as best as you can.

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Self-Image: What is your ideal of the person you are striving to become?Please answer as best as you can.

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Self-Image: What qualities do you especially admire in others?Please answer as best as you can.

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Self-Image: If you were listing three difficult feelings that most often arise in you, what would they be?Please answer as best as you can.

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Self-Image: What are some of your virtues?Please answer as best as you can.

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Self-Image: What roles do you typically play in relations with other people?Please answer as best as you can.

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Attitudes of Others: What expectations have your parents, siblings, teachers, bosses, co-workers, and friends had of you?Please answer as best as you can.

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Attitudes of Others: To what extent have you felt accepted and approved of by these people?Please answer as best as you can.

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Attitudes of Others: What has been your biggest difficulty in relating to others?Please answer as best as you can.

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Attitudes of Others: What do other people like best about you?Please answer as best as you can.

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Goals and Ambitions: What would you like to accomplish, in your own personal development, your family life, your career, your involvement in the community, or in some other area?Please answer as best as you can.

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Other Experiences: In addition to your answers so far, describe any other outstanding experiences, desires, interests, habits, beliefs, relationships, and feelings that have played a major role in your development.Please answer as best as you can.

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Motivation: State your reasons for wanting to work with Dr. Michaelene and/or do the long session. What do you hope to accomplish? What fears have arisen? What questions do you have? What kind of experience are you hoping for?Please answer as best as you can.

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Consent Form

I understand that I have the following rights with respect to therapy:

My treatment information is considered confidential, and the staff will respect my
right to privacy with the except of the following:

Client records and other personal data will only be released with my prior, written approval, and after verbal explanation of the purpose and benefit of releasing such information. The exception is releasing information to accrediting, licensing,
and payor organizations for financial and quality care reviews or to another healthcare provider in an emergency situation or for supervisory needs.

Information may also be released to the proper authorities if it is necessary to keep others or myself from being harmed. This includes abuse, neglect, exploitation, and endangerment.
The information I provide is used to establish a treatment plan. I will participate in the development and implementation of a treatment plan, which will address my treatment needs.
Professional decisions regarding treatment are at the discretion of Michaelene Ruhl, PsyD.
My treatment plan may include medications, psychotherapy, group and individual counseling, referral, follow-up, outreach, and support services.
The result of treatment does not have a warranty or guarantee.
I may discuss with my therapist any concerns or dissatisfactions I have with the care I receive.
Release - Liability for Injury, Loss and Property Damage

The Client hereby releases the management of MRR PsyD LLP, its staff, employees, Board of Directors, interns, and volunteers from responsibility or liability to the Client for any loss, damage, or injury of any nature or kind whatsoever to person or property sustained by the Client or Client’s family while inside or outside the physical confines of MRR PsyD LLP or at any other location where MRR PsyD LLP provides services. MRR PsyD LLP is further released from responsibility or liability for any loss or personal injury caused by other Clients, their family, trespassers, or the management, employees, interns, volunteers, or any staff whatsoever.
Client Fee agreement - I understand that:
No promises or guarantees shall be offered to me concerning treatment services.
I shall be offered the customary and standard treatment.

Termination is usually an agreement between the therapist and myself but I have the freedom to discuss and discontinue treatment at any time.

I realize that:

There is a charge for counseling services and that payment for services is expected prior to receiving services.

I shall be responsible for any charges.

I agree:

To keep scheduled appointments or give 24-hour notice of cancellation. If I give less than 24-hours’ notice of cancellation, I will be charged the full price of the appointment.

I give my permission for treatment, as believed necessary, to the treatment staff, that includes but is not limited to 1) psychological evaluation, 2) readiness for treatment, and 3) right fit or referral potential. I understand that this may bring up issues of a highly personal nature that may cause me to experience emotional or physical responses that may be unexpected and/or unpleasant. By signing below, I willingly agree to the preceding statements and to hold harmless from all liability Michaelene Ruhl, PsyD.

This consent is active and valid until the case is closed.

Please continue to sign this consent.

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SignaturePlease sign below.

Clear

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Date* This field is required.

Date