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iMove Group Interest Form
Please complete this form to provide us with information about your in interest in the iMove group.
* Indicates required question
Email
*
Record my email address with my response
Name (First and Last)
*
Your answer
Age
MM
/
DD
/
YYYY
Email
*
Your answer
Phone Number
*
Your answer
Preferred method of contact
Email
Phone
Either
Gender
Female
Male
Nonbinary
Prefer not to share
Clear selection
Pronouns
Your answer
Home Address
Your answer
Time Zone
Your answer
Are you part of a treatment team?
Yes
No
Clear selection
If you are part of a treatment team, who does it include?
Medical Doctor
Psychotherapist
Psychiatrist
Dietitians/Nutritionist
Other:
Clear selection
Has your doctor cleared you for light activity?
Yes
No
Other:
Clear selection
Can your program facilitators exchange information with your treatment team as needed?
Yes
No
Other:
Clear selection
What are you currently doing for movement? Please include frequency, duration, and type.
Your answer
Can you commit to taking at least one day off of exercise each week and follow the guidelines of your treatment team around physical activity?
Yes
No
Maybe. I am open to working towards this.
Clear selection
Do you have any injuries or medical conditions we should be aware of? Please describe; or if no, reply "none."
Your answer
What are you hoping to gain from participating in this group?
Your answer
Do you have a history of trauma?
Yes
No
Prefer not to share.
Clear selection
Helpful Information. If you answered yes to the above question, is there anything that would be helpful for us to be aware of so that a safe environment can be created for you?
Your answer
Would it be helpful for us to get additional information from your therapist? If so, please provide contact information.
Your answer
Please share any other relevant information you would like us to know, or questions you may have about the group.
Your answer
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