Consent Form

CONSENT FORM FOR ALL THREE GROUPS OF THERAPY

Research Project: Divorced Supportive Therapy

I have been asked to participate in a research study about supportive group therapy for the divorced population. I was selected to be a possible participant because I am divorced. Forty-five people have been asked to participate in this study. The purpose of this study is to determine whether a certain therapy technique is an effective treatment for divorced people who have symptoms of anxiety and depression. If I agree to be in this study, I will be asked to fill out a brief demographic form and complete four questionnaires,i.e., a depression scale inventory, an anxiety scale inventory, a well-being inventory, and a physical symptoms inventory.

I will fill out the four questionnaires three times, at the beginning of the study, the end of group therapy, and three months after the sessions ended. Each of these questionnaires will take approximately 15-20 minutes of my time to complete. I understand that I will be assigned to one of three study groups: two groups will receive treatment (two-hour group therapy sessions for ten weeks, a total of twenty hours of group therapy) and one group will not receive treatment until after the study has been completed. If selected for the wait-list control group, participants will complete three rounds of testing: at the beginning of the study; the end of the ten week support group; and three months after the support group sessions ended. After the three months and testing are completed, the wait-list control group will be offered ten-weeks of group therapy or individual therapy, if so desired. The sessions will be a private-closed group and will be held at the Psychological Services Center at Argosy University, Chicago.

The risks associated with this study are that I may become uncomfortable answering the questions on the demographic form and filling out the depression and anxiety inventory forms. Being part of the group therapy process may cause me to become emotionally upset. Except for my time and inconvenience, there are no other risks to me from participating in this study. The benefits of participation may include an increase in overall sense of well being and the receipt of free counseling services. It is possible that there will be no benefit to me for participating in this study. I will not receive any payment or monetary compensation for participating in this study.

Limits to honoring confidentiality specifically include: if the therapist comes to believe that I am threatening serious harm to another person, he is required to try to protect that person. He may have to tell the person and the police, or perhaps try to have me put in a hospital. If I seriously threaten or act in a way that is very likely to harm myself, he may have to seek to hospitalize me, or call on my family members or others who can help protect me. If such a situation does come up, the therapist will fully discuss the situation with me before he does anything, unless there is a very strong reason not to do do. In an emergency where my life or health is in danger, and he cannot get my consent, he may give another professional some information to protect my life. The therapist will try to get my permission first, and he will discuss this with me as soon as possible afterwards. If the therapist believes or suspects that I am abusing a child, an elderly person, or a disabled person, he must file a report with DCFS, the state agency. To “abuse” means to neglect, hurt, or sexually molest another person. The therapist does not have any legal power to investigate the situation to find out all the facts. The state agency will investigate. In any of these situations, the therapist would reveal only the information that is needed to protect me or the other person.

This study is confidential and my name will not be on any of the documents. A code number will be used to protect my identity. Data will be kept in the investigator’s locked office. My name or other identifying information will not be reported in any publication. The key linking my name to the data will be destroyed after the data analysis is complete, and all the data will be destroyed after five years. The records of this study will be kept private. No identifiers linking me to the study will be included in any sort of report that might be published. My decision whether or not to participate in the study will not affect my current or future relationship with Argosy University.

If I decide to participate, I am free to refuse to answer any of the questions that may make me uncomfortable. I can withdraw at any time without my relations with the university, job, benefits, etc., being affected. I can contact Richard Jakubik at 847-239-2326 or at richard.jakubik@yahoo.com. I understand that this research study has been reviewed and certified by the Institutional Review Board, Argosy University - Chicago. For research-related problems or questions regarding participants' rights, I can contact the Institutional Review Board through the IRB Chair, Dr. David Van Dyke (dvandyke@argosy.edu), or through Dr. Leah Horvath (lhorvath@argosy.edu), the faculty advisor for this study, at 312-777-7600. I have read and understand the explanation provided to me. I have had all my questions answered to my satisfaction, and I voluntarily agree to participate in this study. I have been given a copy of this consent form. By signing this document, I consent to participate in the study.

Signature of Participant: _________________________ Date: ___________
Signature of Investigator:_________________________ Date: ___________