Intake & Assessment Form (no longer used after 9/1/20)
The purpose of this document is to provide our mental health clients with information about Mindful
Bodies counseling staff and to ensure that you have been informed of your rights and responsibilities
within the counseling relationship. By providing your digital signature at the end of this form, you agree that you have read and understood the statements, and that questions you have about this statement have been answered to your satisfaction. Mindful Bodies acknowledges our commitment to conform to the specifications discussed in this statement.
Email address *
Did you fill out Mindful Bodies consultation form & did you or your child (if you are the parent of the client) receive a consultation session on Zoom with Shawnta (pronounced Shawn Tay) Wright? This current form is the intake & consent form. but a few of the questions will be the same as the questions as were on the consultation form.
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Client First and Last Name (include the name that you want to be called if it is other than your Legal Name). Also write parent's name if client is younger than 18 years old
Client Cell Phone Number and/ or Parent's Cell Phone Number if Client is younger than 18 years old (Mindful Bodies counselor will text you to confirm the appointment and give you information about your office visit or virtual counseling session)
Client Birth Date (month, day & year)
Medical Insurance Information (Mindful Bodies may begin billing Medical Insurance in the near future but we currently only accept private pay and sliding fee scale)
Reason(s) for Seeking Individual or Couple's Counseling Mental Health Counseling (check all that apply)
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Please add more Information, if desired, about your reasons for seeking individual or couple's counseling at this time (you may have already given us this information on your consultation/ referral form)
Virtual Counseling Sessions are held on the video conferencing platform or the Mindful Bodies therapist choosing (Ingle, Quanda & Shawnta are our 3 therapists & we sometimes have an Master's Level intern therapist). In person sessions are held at our Mindful Bodies office, 3310 Croasdaile Drive, Suite 301, Durham NC, 27705. Your therapist will text the full details.
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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 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)
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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.
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The Counseling Relationship: During the time that we work together we may meet weekly in groups, in couples/ family sessions, or individually. Group sessions meet for 75 – 90 minutes & individual & couples sessions meet for 50 - 60 minutes. 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 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.
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The Gottman Method of Couple’s Therapy is based on Dr. JohnGottman’s research that began in the 1970’s and continues to this day. The research has focused on what makes relationships succeed or fail. From this research, Drs John & Julie Gottman have created a method of therapy that emphasizes a “nuts-and-bolts” approach to improving clients’ relationships. This method is designed to teach specific tools to deepen friendship and intimacy in your relationship. To help you productively manage conflicts, you will be given methods to manage “resolvable problems” and dialogue about “gridlocked” (or perpetual) issues. We will work together to help you appreciate your relationships’ strengths and to gently navigate its vulnerabilities. Gottman Method Couples Therapy consists of 5 parts: 1) Assessment (3 sessions), 2) Treatment, 3)“Phasing Out” of Therapy, 4) Termination and 5) Outcome Evaluation. Early In the assessment phase,you will be given some written material to complete that will give us a better understanding your relationship, areas of concern & goals for treatment. In the 2nd session, the therapist will meet with each partner individually (45 minutes per session) to learn your personal histories & to give each person an opportunity to share thoughts, feelings & perceptions. In the 3 rd session which is the final assessment session, the therapist will share their recommendations for treatment & will help to define mutually agreed upon goals for therapy.Most of the work will involve sessions where you will be seen as a couple. However, there may be times when individual sessions are recommended. The therapist may also give you exercises to practice between sessions. The length of therapy will be determined by your specific needs and goals. In the course of therapy, we will establish points at which to evaluate your satisfaction and progress. In the later course of therapy, we will “phase out” or meet less frequently in order for you to test out your new relationship skills and to prepare for termination of the therapy. In the outcome-evaluation phase 4, follow-up sessions are planned, 1 after 6 months, 1 after 12 months, 1 after 18 months and 1 after 2 years. These sessions have been shown through research to significantly decrease the chances or relapse into previous, unhelpful patterns.
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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.
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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.
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Fees: 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. Payment is expected at the time of service. We accept payments on our website or with cash, credit card, or personal check. We currently do not bill Medicaid or other forms of insurance at this time but we can attempt to bill out of network with your insurance company. If you require documentation to provide to your medical care provider, please inform us of your need & we will make an effort to provide you the necessary information. .
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You have already answered this question on our consultation form but we are confirming the information again about fees for counseling sessions, just in case your situation has changed since you filled out the form. Do you need to use our sliding fee scale for your mental health counseling sessions? Payments for sessions will be made at
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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.
Medical Records and Diagnosis: Federal & state laws require that personal medical information be maintained in a safe and confidential way. If you require a copy of all or part of your medical record,please make an appointment with us to review the information needed. In order for you to file insurance for reimbursement, we are typically required to provide a diagnosis of your mental health condition. Any diagnosis made will become part of your permanent medical record. We will make every effort to inform you of the diagnosis that we plan to provide before committing this information to your medical record. Session Audio or Video Recording: If your counselor is a graduate student, they may ask to record your session so that their professors can assess their counseling skills. Gottman Couples Therapist may also ask to record your session & the recording will be used in the couple’s session to illustrate to the couple, their communications skills. The consent form for video or audio recording sessions is a separate form so by signing this document, you have not consented to having your session(s) recorded for clinical purposes. You must sign an additional consent form to consent in order to have your session(s) recorded. Clients may record their individual sessions & couples sessions but please notify your counselor that you plan to record the session.
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Please list any comments or questions that you have about your client rights, informed consent to counseling or any other items on this intake form. You may also contact Shawnta (pronounced Shawn Tay) Wright, Mindful Bodies owner at 919-812-3172 or with any questions.
The purpose of this document is to provide our mental health clients with information about Mindful Bodies counseling staff and to ensure that you have been informed of your rights and responsibilities within the counseling relationship. By providing your digital signature (name & email address) in the space below, you agree that you have read and understood the statements in this document, & that questions you have about this statement have been answered to your satisfaction. Mindful Bodies acknowledges our commitment to conform to the specifications discussed in this statement. Please type your digital signature below
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