MB Referral Form for Individual Mental Health Counseling (To be filled out by potential client, client's guardian or by Mindful Bodies counselor)
A Mindful Bodies Therapist will contact you within 1 week (5 business days) of receiving this form. You can also text Shawnta (pronounced Shawn Tay) Wright at 919-812-3172 if no one has contacted you within 1 week of your form submission.
Name of Person who is Making the client referral (If this is a Self-Referral and you are the client, please write self referral and give us your name later on the form when client name is requested):
Phone number of person who is making the referral (if this is a Self- Referral & you are the client, please write self referral and give us your contact information later on the form when it is requested):
Email of the person who is making the referral (if you are a self-referral, please write self referral)
Which Mindful Bodies counseling service does the client want?
Individual Counseling for an Adult (18 yrs or older)
Individual Counseling for a teen or child (8 yrs - 17 yrs old)
Gottman Couples Counseling
Client or Clients Name(s): (If you are seeking Gottman Couple's counseling, please list both partners names)
Client Mailing Address: (if you are seeking Gottman Couple's Counseling & both partners do not reside at the same address, you can give the address of the person who is filling out this form)
Client(s) Cell phone number: (Gottman Couples can either give both partner's phone numbers or just the person's cell phone # who is filling out this form)
Client(s) Email address: (Gottman Couples can either give both partner's email's or just the person's email who is filling out this form)
Client(s) Date of Birth: (If you are seeking Gottman Couple's counseling, please list both partners birthdates)
Client Ages): (If you are seeking Gottman Couple's counseling, please list both partners ages)
If client is younger than 18 - list guardian name & contact information (if the guardian is the person who is making the referral and you already listed your contact information above , then please write "see above answers":
Client(s) Gender Expression/ Gender Identity:
Client(s) Race/ Ethnicity
Client Marital/ Relationship Status
Is Client a Parent? If yes, how many children do you have?
How did you hear about Shawnta Wright or Mindful Bodies Mental Health Counseling services? (from a friend, from another therapists, from psychology today, from social media, etc)
Mindful Bodies does not currently accept 3rd party payments such medical insurance for session payment . We are not currently paneled with any insurance companies but we plan to start the insurance credentialing process in Jan 2021. We accept private pay so clients will pay out of pocket for their sessions . Some clients have been able to use their Health Savings Account that is provided to them by their jobs to pay for sessions. We offer sliding fee scale (pay between $35 to the $100 full session rate to see fully Licensed & Associates level Licensed Clinical Mental Health Counselors (LCMHC) . If Mindful Bodies has a Master's Level intern then we may be able to offer sessions for less than the $35 cut off sliding fee amount. The amount the client will pay for sessions will be agreed upon during the $Free consultation session.
Yes, I understand
No, I do not understand
More information is needed. Please text Shawnta at 919-812-3172 with your questions
Do you need to use our sliding fee scale for your mental health counseling sessions? Payments for sessions will be made at
Yes, I can not afford the full $100 session fee & need the sliding fee scale ($35 - $100 full session rate)
No, I do not need to use the sliding fee scale and can pay the $100 full session rate
Please list all of client's past or present mental health diagnoses. Please specify if your are currently experiencing mental health diagnoses or if the diagnosis has been treated and you are no longer experiencing problems.
Has the client had any past or present suicidal thoughts or suicide attempts (please explain). If you are having suicidal thoughts right now, please contact 911 or contact the suicide prevention lifeline at 1-800-273-8255 or go to
Has the client been hospitalized for mental health concerns (please explain)
Client Substance Use Disorder & Addictions History (includes past & current problems with diagnoses alcohol, drugs, gambling, sex, pornography, gaming, internet addictions, etc)
Please list client’s strengths & positive traits. Mindful Bodies counselors help our clients build on their strengths.
Please describe the client’s support system (family, community, friends, etc)
Please list the reasons for client referral or self referral to counseling at this time:
What are the client's immediate (in the 1st month), medium term (from month 2 - month 6) and long term (month 7 until termination of counseling) therapy goals?
Has the client been in therapy in the past or is the client currently in therapy?
Yes, I used to have a therapist in the past but that realtionship has ended
Yes, i currently have another therapist
Kind of - I went to 1 or 2 therapy sessions in the past but "it didn't stick"
No, I have never been to even 1 therapy session before
Other (it's complicated)
What are the client's thoughts, beliefs or feelings about therapy or the therapy process? It can be important to address barriers to therapy in the consultation session.
Please list any additional pertinent client information:
Next Steps: At this moment (it doesn't matter if it is late at night or early in the morning) . Please text Shawnta at 919-812-3172 and notify her that you have competed this consultation form
Yes I just texted 919-812-3172
No, I did not text 919-812-3172
Please note that all potential counseling clients will 1st fill out this consultation/referral form then will will schedule a $FREE consultation session on Zoom with a one of the Mindful Bodies mental health counselors to discuss the information on the referral form. The potential client is encouraged to ask the counselor questions about their counseling experience & how they plan to help them achieve their goals. At the end of the consultation session, the counselor & potential client can decide if they are a good fit for each other and both parties can decide when to schedule the 1st counseling session which can be held in-person at the Mindful Bodies office or on Zoom. The 1st counseling session will consist of the client filling out intake paperwork which usually takes 5 - 10 mins then there will be an actual counseling session - no lengthy assessment. Find out more about Mindful Bodies at www.mindfulbodies,net.
yes, I understand & agree
no, i do not understand & i do not agree
I need more, information. Please text 919-812-3172
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service