Chrysalis
Questionnaires 
printable
Questionnaires
To download the questionnaires,
<click> on each
of the 3 names: 
 Intake
Symptoms 
 SRH 
By clicking
the form name,
it is downloaded.
Print each form, 
answer the questions, then take the forms 
to your appointment.
Out-Take 
When you have completed your Chrysalis Care,
please download,
the
Out-Take form
fill it out and
send, or take it,
to your Practitioner.

HIPAA Notice

Chrysalis Patients and Clients who choose to “opt-in” to preserve their information in the Chrysalis database, maintain their privacy.   

When opting in,  Questionnaire answers and Chrysalis sessions are reserved in anonymous form for their Practitioner’s access, for the restoration of their Practitioner’s local device (if it  requires replacement (due to loss, breakage or upgrade)) and for generalized research purposes.

In protection of patient/client privacy, there is no Patient Identifiable Information transferred to the Chrysalis database.

When a Patient/Client Opts-In, the Chrysalis database information allows the Practitioner to

  • ​access encrypted questionnaire responses by using their password-protected portal to the database,

  • review past session data for optimization of treatments,

  • repopulate a new device with database saved information, which would otherwise be lost,

  • contribute to studies of quantification across all opt-in clients, enabling better understanding of improvements in functioning and assessing how to further increase them.

 

Your use of our online Questionnaires implies you are Oping-In. 

By Opting In, you are agreeing to have your information anonymously saved in the Chrysalis database, and agree to have it used as described above.  

The e-mail address you provide when accessing our online Questionnaire system  will be used to create a unique anonymous identity – as is the case for each opt-in client 

 

Your  Practitioner will require knowledge of the Questionnaire e-mail address you use, (which may be a  different email address than the one use to communicate with one another).  Be sure to coordinate with your Practitioner as to  which e-mail address is appropriate for each  purpose. 

Your identity is unknown to Dr. Len Ochs' company. Your encrypted Questionnaire e-mail address (used to access your anonymous database information) is only known to you and your Practitioner.   

If you prefer to use an alternative e-mail address for accessing the Questionnaires, feel free to create a new e-mail account for that purpose. 

 

If you and your Practitioner choose to communicate  by e-mail at times, be sure to inform her/him as to which e-mail address to use for each purpose.  

 

Any Client not in agreement with the intent of this notice, may access pen and paper questionnaires.   Each forms can be downloaded and printed.   After  filling them  out, please take the forms to your appointment with your Practitioner.

How do you get the printable questionnaire forms?

In the Questionnaires box above, on the left.

online
Questionnaires

After

reading the

HIPAA notice,

if you choose to

OPT-IN,

proceed to the

online questionnaires

>>  HERE  <<

Opt-In
Opt-Out
 
Hank Virgona

 Dr. Len OchsPrivate Practice  - 707.396.3598

While this website contains information not generally known, all of it has been acquired over my lifetime.  I am required to state however, none of this information is for treatment or diagnosis of any medical or psychiatric purpose.  It is provided for entertainment only.

Special thanks to Patrick Amiot and Brigitte Laurent  for their wonderful whimsical sculptures in Sebastopol.

(c) Copyright 2018 Len Ochs Ph.D. All Rights Reserved