Staff MB Consultation, Referral & Consent Form for Individual Mental Health Counseling (To be filled out by potential client, client's guardian or by Mindful Bodies counselor)
After you have completed this form, please email
& one of them will email you, within 7 business days, to schedule a $Free consultation session on Zoom. You may also contact Shawnta (pronounced Shawn Tay) Wright at 919-812-3172 or
. Please note that Mindful Bodies is only insured and licensed to provide consultation & counseling services to people who live in NC.
the client (or clients - if couples counseling is being requested)
the parent of the client
I am a social worker, mental health professional, etc who is referring a client for services
the child of the client
Which Therapist Do You Want to See?
Pamela Clarke, Intern
Katherine Rogers, LCMHCA
Ingle Reid, LCMHCA
Quanda Lunsford, LCMHC
Erica Ybarra, LCMHCA
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)
My First and Last Name is: (please indicate if the name you want to be called is different than your "government name". If you are seeking couple's counseling, please type both partners names. if you are the parent of the client, please list your name and your child's name)
My Cell Phone Number is (if you are seeking couples counseling, please list both partners cell phone numbers):
My Email is (if you are seeking couple's counseling, please list both partners email addresses)
Client Mailing Address: (this information will only be used to send forms to client - if needed). Please note that Mindful Bodies is only licensed and insured to provide consultation and counseling services to people who reside in NC
Client Date of Birth: (If you are seeking couple's counseling, please list both partners birthdates)
Client Age: If you are seeking couple's counseling, please list both partners ages)
Client Gender Expression/ Gender Identity:
Client Race/ Ethnicity
Client Marital/ Relationship Status
Is Client a Parent? If yes, how many children do you have?
How did you hear about Mindful Bodies Mental Health Counseling services? (from a friend, from another therapist, from psychology today, from social media, etc)
Mindful Bodies accepts payments from EAP (Employee Assistance Programs) companies but does not currently accept any medical insurance for session payment . We are not currently paneled with any insurance companies but we may do so in the future. 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 (HSA) , which 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 clients agree to see a Mindful Bodies Master's Level intern then their counseling sessions are $free of cost
Yes, I understand
No, I do not understand
More information is needed. Please text Shawnta (pronounced Shawn Tay). Mindful Bodies owner, at 919-812-3172 with your questions
Do you need to use our sliding fee scale ($35 - $100 per session) for your mental health counseling sessions? Payments for sessions will be made at
Yes, I can't 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
No, I do not need to use the sliding fee scale because my EAP is paying for my sessions
No, I am seeing a MIndful Bodies intern so my sessions are $free of cost
Unsure. More information is needed, please text Shawnta, Mindful Bodies owner at 919-812-3172
If you selected "yes" for the sliding fee scale. How much can you afford to pay ($35 - $100) for you sessions. Please do not worry about shortchanging Mindful Bodies. We want to make sure counseling is affordable for everyone who seeks out our services.
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)
Reason(s) for Seeking Individual or Couple's Counseling Mental Health Counseling (check all options that apply . also, please note that the following question will allow you to more fully elaborate on your needs)
Relationship concerns with partner (may include communication, problem solving, intimacy, etc)
Friendship and/or co-worker concerns
Covid 19 Quarantine related stressors
Black Lives Matter (BLM) related stressors/ Racial Trauma/ Discrimination & Oppression
LGBTQIA+ related stressors or trauma/ Discrimination & Oppression
Depression or Bi-polar disorder 1 or 2
Grief, loss or Bereavement
Self Esteem/ Self Worth concerns
Eating or Weight Concerns (Bulimia, Body Image, Binge Eating Disorder, Anorexia, general weight management)
Trauma (past or current homelessness, child abuse, sexual abuse or domestic violence, or other traumas)
Excessive Behaviors (gambling, sex, spending money, exercise, work, etc)
Body Image/ Body Dissatisfaction (does not necessarily have to be related to weight)
Finding Meaning , Purpose or Satisfaction in Life
Help with problem solving, decision making, coping skills or acceptance of an issue that can't be changed
Other concerns - not listed above (please elaborate on the question below)
Please include any additional reasons that the client is seeking counseling or elaborate on the boxes that you checked above (also, please indicate if the client is mandated to participate in counseling by the court system, child protective services, etc.)
What does the client want to gain, overall, from counseling (please list your short term, medium term & long term counseling 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. feel free to elaborate in the following question)
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.
Do you want Virtual or In-Person Counseling Sessions? You can elaborate on your preferences on the following question.
I want Virtual Counseling Sessions (Mindful Bodies holds our sessions on Zoom Videoconferencing)
I want In-person Counseling Sessions (In-person sessions are held at our Mindful Bodies office)
I want a combination of Virtual & In-person Counseling Sessions
I do not have a preference and either Virtual & In-Person Sessions are OK
Please elaborate, if needed, on your preference for Virtual or In-Person counseling sessions
What time of the day / week are you available to meet for counseling sessions? This question allows you to check multiple options .
Monday - Friday - 9 am - 5 pm
Monday - Friday - 5 pm - 9 pm
Saturdays 9 am - 12 pm
Saturdays 12 pm - 5 pm
Sundays 12 pm - 5 pm
Please elaborate, if needed, on the time of day / week that you are available for counseling sessions
Please list any additional pertinent client information that you want to share with Mindful Bodies:
Qualifications: Mindful Bodies counselors are Licensed Clinical Mental Health Counselor Associates (LCMHCA), Licensed Clinical Mental Health Counselors (LCMHCS) & interns/ practicum students who are supervised by their University professors & by Mindful Bodies staff . If you are dissatisfied with the services of Mindful Bodies clinical staff, contact Shawnta (pronounced Shawn Tay) Wright at 919-812-3172 or
. You also have the right to report your complaint to the North Carolina Board of Licensed Clinical Mental Health Counselors (NCBLCMHC), PO Box 1369, Garner NC 27529, phone 919-661-0820). Please note that a copy of Mindful Bodies Disclosure Statement can be found at
(under the services tab - then under the client forms tab)
yes, i agree & consent
no, i do not agree. i do not consent
not sure. I have questions. please contact shawnta (pronounced shawn tay) wright, mindful bodies owner at at 919-812-3172 with questions
Services & Nature of Counseling: Mindful Bodies offers office-based & virtual mental health therapy to adults, children & teens for issues including but not limited to general weight management, Binge Eating Disorder (BED), Bulimia Nervosa (BN), disordered eating, emotional eating, domestic violence, sexual assault, self-esteem, assertiveness, life transitions, adolescent issues, family and couples issues, relationship issues, identity development, life/work balance, parenting, anxiety, depression, PTSD , stress management, Gottman Couple's Counseling & more. The Nature of Counseling: Counseling provides a safe, supportive & accepting space for self-exploration & growth. We strongly believe in a collaborative client-counselor relationship. Our approach to counseling is based on the theories of Person-Centered Therapy, Cognitive Behavior Therapy, Motivational Interviewing, Wellness-Based Counseling, Mindfulness, Brief Solution Focused Therapy and Gottman Method Couples Therapy.
yes, i agree & consent
no, i do not agree. i do not consent
not sure. please text shawnta wright, mindful bodies owner, at 919-812-3172 with questions
The Counseling Relationship: During the time that we work together we may meet in groups, in couples/ family sessions, or individually. Group sessions meet for 75 – 90 minutes & individual & couples sessions meet for 50 - 60 minutes. Some clients schedule individual and couples sessions on an as needed basis, or on a weekly, bi-weekly, or monthly basis. Our time spent together may be emotionally intimate but it is important to understand that our relationship is professional, not social. Our contact will be limited to the counseling sessions we arrange, except in the rare case of an emergency. We do not discriminate on the basis of age, race, ethnicity, gender, religion, national origin, sexual orientation, or physical disability & we are radically affirming - LGBTQ+ allies. We will refer you to another agency if the issues that you are experiencing are outside of the scope of our experience or training.
yes, i agree & consent
no, i do not agree & i do not consent
not sure. please text shawnta, mindful bodies owner, 919-812-3172 with questions
Client Rights/ Termination: You are in control of your counseling experience & are free to end our relationship at any time. If you decide to end your counseling sessions, we ask that you discuss this decision with your Mindful Bodies therapist. All of our therapists are available to discuss the positive or negative effects of beginning, continuing or ending the counseling process. If you are dissatisfied with our services, please let us know. If we are not able to resolve your concerns together, you have the right to report your complaint to the North Carolina Board of Clinical Mental Health Counselors (NCBCMHC, PO Box 1369, Garner NC 27529, ph: 919-661-0820). Cancellations: If you are unable to keep an appointment, please notify us at least 24 hours in advance. We reserve the right to charge you a $25 late cancellation fee. If you fail to attend 3 sessions without the appropriate notification, we may request to terminate our counseling relationship, at which time we will provide you with appropriate referrals to other counseling professionals.
yes, i agree & consent
no, i do not agree & i do not consent
not sure. please text shawnta, mindful bodies owner, at 919-812-3172 with questions
Confidentiality: Most of our communications are considered confidential & are protected by federal & state laws. There are some circumstances in which we are permitted or required to disclose information about you: a) you provide Mindful Bodies with your consent to release information; b) there is a reasonable suspicion that you are a threat to yourself or someone else; c) you disclose abuse or neglect of a child, elderly or disabled person; d) Mindful Bodies is ordered by the court to disclose information; or e) we are otherwise required by law to release information.
yes i understand & consent
no, i do not understand. i do not consent
I am unsure & i have questions. Please text Shawnta, mindful bodies owner, at 919-812-3172
Please note that all prospective counseling clients will 1st fill out this consultation/referral form then 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 prospective 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 & prospective client will decide if they are a good fit for each other and both parties will decide if & 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 be an actual counseling session & will not be spent filling out forms. Mindful Bodies forms can be found at
under the services tab - then under the client forms tab.
yes, I understand & agree
no, i do not understand & i do not agree
I am unsure & i need more, information. Please text shawnta, mindful bodies owner, at 919-812-3172
now and state that you have completed your consultation form. A staff member will email or text you back, within 7 business days, to schedule your $free consultation on Zoom. Consultation sessions take between 30 - 60 minutes and will help the prospective client and counselor decide if they are a good clinical fit for each other.
yes, i understand & agree
no, i do not understand. I do not agree
I am unsure & i need more information, Please text Shawnta, Mindful Bodies owner, at 919-812-3172. You are welcome to text Shawnta at any time and will not be bothering her if the text is late or early because she turns off her phone if unavailable
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