FM/FB (Fit Mind/Fit Body) Intake Form
Please fill out this form to enroll in the 12 week Fit Mind/Fit Body CBT (Cognitive Behavior Therapy) Weight Management Group. You may also attend an optional virtual interest session to ask questions about the program but attendance at an interest session is not required but the intake form must be completed prior to the 1st group session. After you complete the intake form, you will be added to the FM/FB group member text & will receive weekly group members reminders.

Our FM/FB group is a Cognitive Behavior Management (CBT) group so is a talk therapy group where participants meet together each week for 75 minute long sessions to learn, discuss & practice 10 weight management skills. The cost of group is $20 per group session & discounts are given for multiple session payments. Sliding fee scale (pay what you can afford between $5 - $20 per session) is available. Payments can be made on www.mindfulbodies.net . Mindful Bodies staff, volunteers, LCMHCA supervisees, interns & practicum students pay $0.

Pre-Payment Discounts are as follows: One session at a time = $20 each session, 4 sessions in advance ( 15% discount . total due = $ 68 instead of $80), 6 Sessions in advance (20% discount . total due = $96 instead of $120), 12 session in advance (25% off .total due = $180)

FM/FB participants receive 1 complimentary ($Free) Virtual Small Group Personal Training (SGPT) Session, each week, while enrolled in FM/FB group. Our Virtual SGPT sessions are held on Mon & Wed at 4:45 pm - 5:30 pm on Zoom. SGPT attendance is optional and FM/FB participants are not obligated to attend. We are offering SGPT as a bonus & as a way to help FM/FB participants achieve their weight management goals,

Please note that Former FM/FB group members can attend future FM/FB groups at no cost & they do not need to fill out this intake form but they must pay to attend SGPT sessions.
Email address *
Client Name
Client Age and/or date of birth
Client Cell Phone Number
Client Mailing Address
FM/FB group is a Cognitive Behavior Therapy (CBT) talk therapy group where group members meet with a group facilitator who is a Licensed Clinical Mental Health Counselor for 12 weeks for 75 minute sessions. FM/FB group once per week on Saturdays at 11 am - 12:15 pm. If there is enough participant interest (at least 5 people interested in different group sessions), we may also hold a Sunday 12:30 am - 1:45 pm group but the same session information will be repeated at the 2 sessions so participants would only need to attend either the Sat or Sun session. Which of our two session times works best for your schedule? ___________________________________________
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If the above times, do not work well for your schedule, please list other times & days that do work for you? If desired, please also comment on anything related to group time.
Which of our 10 FM/FB skills most interests you most? Choose all that apply
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FM/FB participants will be given the link to the digital FM/FB group manual, which we will use each week in the 75 min long sessions. Here is the FM/FB Agenda for the weekly sessions: Home Practice Check-ins – (40 mins) Topic of the Day - the FM/FB skills (30 mins)Home Practice Activities (5 mins)Post Group Payment Collection (payments can be made prior to group or on our www.mindfulbodies.net website)
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FM/FB participants receive 1 complimentary ($Free) virtual Small Group Personal Training (SGPT) Session, each week, while enrolled in FM/FB group. Our Virtual SGPT sessions are held on Mon & Wed at 4:45 pm - 5:30 pm on Zoom. SGPT is optional and is a bonus that we threw in to help FM/FB participants achieve their weight managment goals. Are you interested in attending virtual SGPT sessions?
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Please tell us about your weight management history (how many times you have attempted and lost or regained weight, when you first started to lose weight, which programs you have tried - ie - weight watchers, nutrisystem , jenny craig, etc)
Please tell us about your eating disorder history? Have you ever been Diagnosed or Hospitalized with an Eating Disorder (binge eating disorder, bulimia, anorexia, etc) or do you feel like you may have an Un-Diagnosed Eating Disorder? If yes, please elaborate.
Please tell us about your weight management & non- weight management related goals (Our FM/FB group is about so much more than physical weight)
Please tell us anything else that you want us to know about you
Payments will be made on our www.mindfulbodies.net website. The cost of the FM/FB group is $20 per week and discounts are given if multiple sessions are paid for at the same time, We don't want price to be a barrier to group attendance so we offer a sliding fee scale (pay what you can afford between $5 - $20 per session) for all Mindful Bodies services. Mindful Bodies staff, volunteers, interns/ practicum students & LCMHCA supervisees pay $0. How much do you plan to pay for your group sessions?
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Pre-Payment Discounts: One session at a time = $20 each session, 4 sessions in advance ( 15% discount . total due = $ 68 instead of $80), 6 Sessions in advance (20% discount . total due = $96 instead of $120), 12 session in advance (25% off .total due = $180). Mindful Bodies staff, volunteers, interns/ practicum students & LCMHCA supervisees pay $0. Group Payments can be made on www.mindfulbodies.net (there is a payment screen on each page of our website)
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Do you know anyone who might be interested in attending the FM/FB program? Please include their name & cell phone number below.
If you are undecided about joining the program or are unable to do the program at this time, may we contact you at a later date about future groups and programs?
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I understand that Mindful Bodies 12 week Fit Mind/Fit Body CBT (Cognitive Behavior Therapy) Weight Management Group is a talk therapy group/ mental health program. It is not a fitness program. I understand that it is optional for me to attend a virtual FM/FB interest session where I can ask questions about the program but attendance at an interest session is not required but the FM/FB intake form must be completed prior to the 1st week of group. I understand that FM/FB group participants meet together each week for 75 minute long sessions to learn, discuss & practice 10 weight management skills. I understand that FM/FB participants receive 1 complimentary ($Free) virtual Small Group Personal Training (SGPT) Session, each week, while enrolled in FM/FB group. Virtual SGPT sessions are held on Mon & Wed at 4:45 pm - 5:30 pm on Zoom. SGPT attendance is optional and FM/FB participants are not obligated to attend & the SGPT sessions are a bonus & a way to help FM/FB participants achieve their weight management goals & non-weight management goals. I understand that FM/FB group facilitators are Licensed Clinical Mental Health Counselors & will hold in confidence anything that I tell them except harm to self or others.
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I agree to keep confidential the names of the other FM/FB group participants & the information they share in group. FM/FB group facilitators will also keep confidential the names & information shared by group members with the EXCEPTION of when group members say that they will kill or harm themselves or others.
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FM/FB Interest Session Dates & Times & other Mindful Bodies information can be found on the www.mindfulbodies.net website on the news & events page & on Mindful Bodies Facebook page. Payments can also be made on our website.
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Please Text Shawnta at 919-812-3172 when you have completed this form & write "FM/FB intake form completed" & then you will be added to the FM/FB group member text and receive weekly group member reminders.
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