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Questionnaire & Consent Form
Questionnaire & Consent Form
Please fill out the following questionnaire before your visit.
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  • 12

    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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  • 54

    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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