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. 

Follow Up & Consent Form

Follow-up
     Please schedule a follow-up/integration session 1 to 5 days after an immersion session and then 3 to 4 weeks after that, to discuss how things have changed for you, what you saw and noticed, what you are experiencing now, and how your integration process is going.

Please continue to read and sign the consent form and finish this questionnaire.

Consent Form

By signing this, I agree that I have answered all questions to the best of my knowledge and that I will inform the facilitator of any changes in my condition or medication. 

I also agree that: 

1. I have had the opportunity to ask any questions and have received satisfactory answers. 
2. I fully understand that the use of entheogens can result in a profound change in mental state and may result in unusual psychological and physiological effects. 
3. I understand the risks and benefits, and I freely give my consent to participate in psychedelic use outlined by the facilitators.
4. I understand that the facilitator cannot diagnose any illness, disease, or any physical disorder and that nothing said in sessions should be construed as such.
5. I understand that entheogen use is not a cure for anything, but a therapeutic and spiritual tool to be used in conjunction with other supportive activities.
6. I understand that certain conditions or medications may contraindicate (not permit) entheogenic use.
7. I certify that I am physically fit, have sufficiently prepared for participation in this activity, and have not been advised to not participate by a qualified medical professional.
8. I certify that there are no health-related reasons or problems which preclude my participation in this activity.
9. I respect the decision of the facilitators and am fully responsible for participation status.
10. I understand that my facilitators are providing this experience for me at my request and are not responsible for the outcome of the session.
11. I understand that under no circumstances is there to be sexual solicitation between myself and the facilitators or other participants.
12. I agree to abide by the guidelines and safety restrictions imposed by the facilitators and location.
13. I understand the importance of confidentiality and will not share any information regarding this event unless otherwise approved by the facilitators.
14. I agree to participate in the process and understand the facilitator cannot “fix,” “heal,” or “save” me.  
15. I understand that this experience 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.
16. I hereby assume all the risk of participating in any/all activities associated with this event and hold the facilitator harmless.

I understand that I have the following rights concerning therapy:

My treatment information is considered confidential, and the staff will respect my right to privacy except 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 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.
• Professional decisions regarding treatment are at the discretion of Michaelene Ruhl, PsyD.
• The result of the 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, co-facilitators, interns, apprentices, 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 families, 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.
• There is a charge for services and payment for services is expected before receiving services.
• I shall be responsible for any charges.

I agree:

• To keep scheduled appointments or give 24-hour notice of cancellation for Intention/Prep and Integration sessions and 2 weeks’ notice for the Immersion session. 
• If I give less than 24 hours or two weeks' notice of cancellation, I will be charged $200 for Intention and Integration sessions and $750 for Immersion sessions. 
• I will be charged my full session fee for any session offered if I give no notice of cancellation.
• Please note you do have the opportunity to reschedule your Immersion session within 6 months of your original date if notified within the parameters above and one month for other sessions offered.

By signing below, I willingly agree to the preceding statements and to hold harmless from all liability Michaelene Ruhl, PsyD LLC. This consent is active and valid until the case is closed.

Please continue to sign this consent.