Psychology

Northern Arizona UniversityPsychology

928-523-3063

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SBS
Psychology
Health Psychology Center
Weight Research Form

Health Psychology Center Women's Weight Research Program

Weight group participation form

Please tell us you heard about our program (friend, newspaper, online etc.)First Name: Middle Initial: Last Name: Address City: Zip Code:Home phone : Age:Occupation:Cell Phone: Work Phone: Email:Please provide your current height and weight. This information is needed to determine study eligibilityHeight:Weight: Refer to this BMI chart to confirm that you meet the program criteria of a BMI of 25 or above. I am submitting my name and information for participation in the weight group program.

I understand that I must commit to one weekly meeting which will be held for 10 weeks, beginning February 4th, on Monday evenings from 5:30 to 7:00 pm. I understand that my attendance at the walking activity on Wednesday evening from 5:30 to 6:30 pm is not required but is strongly encouraged.
I understand I must submit the provided physician's release form before the program begins. (Form found on previous program detail page.)
I do not have an eating disorder, either currently or within the past year, such as anorexia (starving) or bulimia (purging).
I do not suffer from untreated depression (moderate to severe).
I am able to walk without restrictions.

You will be contacted after January 4, 2013, when the Health Psychology Center reopens from the holiday break.