Youth--Other

Youth—Other

Attachment B: System of Care Assessment

Youth Stipend Receipt

Date:

__________________________________

Project:

CMHS #633430.0.00x.00.001

Location:

__________________________________

I, _____________________________________, received $15.00 for my participation in an
(Print Name)

interview for the national evaluation of the Comprehensive Community Health
Services for Children and Their Families Program.

_____________________________________
(signature)

System/Program__________________________

Interviewer___________________

Interviewed______________________________

Assessment #_________________

Informed Consent
System of Care Assessment
Youth (18–21 years old)
Purpose
The (name of grant program) in your community provides services to children and youth and their families. The
Center for Mental Health Services in the Federal government wants to know more about these services. They want to
know how well these services work. The National Evaluation Team is talking to children and youth and their families
in (name of grant program) to learn more about how to make these services better. I would like to ask you some
questions about (name of grant program). You will be able to tell me what you think about the program and the
services you have received.
This interview will last about 45 minutes. To help you decide if you want to participate in this interview, here are
some things to know:


Your participation is voluntary and completely by your own choice.



You may choose to stop the interview at any time and for any reason. You also may choose not to answer any
of the questions.



The information you provide to us will be carefully protected. Your name will not be used in any reports
from this interview.



You will receive $15 in appreciation for meeting with me today.

•

We have obtained a Certificate of Confidentiality (CC) from the U.S. Department of Health and Human
Services (DHHS) to keep anything that you tell us private. This means that we will not tell anyone what you
tell us even if a judge tries to force us to identify you as a person in the study. You should know, however,
that we may tell local authorities if harm to you, harm to others, or if child abuse/neglect becomes a concern.
Also, the government agency that has provided the money for this project may see your information if they
ask for our records to ensure we were conducting the project correctly. The CC that we have does not mean
that DHHS approves or disapproves this project.



You will not get any benefit from participating in the interview. A risk is that you may feel uncomfortable
about answering questions about your experiences in (name of grant program).



I will answer any questions you have about this interview before we begin. If you have questions after the
interview is over, you may contact Freda Brashears at ICF Macro, Atlanta, GA. Her toll-free telephone
number is 1-866-368-5657.

Voluntary Consent
I read this form or it has been read to me. I understand what it says. My questions (if any) have been answered. A copy
of this form will be given to me. By signing my name below, I freely agree to participate in this interview.
Participant Printed Name _________________________________________________________
Participant Signature __________________________________________________________________
Witness__________________________________________________________Date________________

CMHS National Evaluation
Phase VII February 2011

2 signed forms: 1 for the interview participant and 1 for the interviewer

System/Program__________________________

Interviewer___________________

Interviewed______________________________

Assessment #_________________

Informed Assent
System of Care Assessment
Youth (14–17 Years Old)
The (name of grant program) in your community provides services to children and youth and their families. The
Center for Mental Health Services in the federal government wants to know more about these services. They
want to know how well these services work. The National Evaluation Team is talking to children and youth and
their families in (name of grant program) to learn more about how to make these services better. I would like to
ask you some questions about (name of grant program). You will be able to tell me what you think about the
program and the services you have received.
This interview will last about 45 minutes. To help you decide if you want to participate in this interview, here are
some things to know:


Your participation is voluntary and completely by your own choice.



You may choose to invite your parent or caregiver to sit in on the interview.



You may choose to stop the interview at any time and for any reason. You also may choose not to answer any
of the questions.



The information you provide to us will be carefully protected. Your name will not be used in any reports from
this interview.



You will receive $15 in appreciation for meeting with me today.

• We have obtained a Certificate of Confidentiality (CC) from the U.S. Department of Health and Human
Services (DHHS) to keep anything that you tell us private. This means that we will not tell anyone what you
tell us even if a judge tries to force us to identify you as a person in the study. You should know, however,
that we may tell local authorities if harm to you, harm to others, or if child abuse/neglect becomes a concern.
Also, the government agency that has provided the money for this project may see your information if they
ask for our records to ensure we were conducting the project correctly. The CC that we have does not mean
that DHHS approves or disapproves this project.


You will not get any benefit from participating in the interview. A risk is that you may feel uncomfortable
about answering questions about your experiences in (name of grant program).



I will answer any questions you have about this interview before we begin. If you have questions after the
interview is over, you may contact Freda Brashears at ICF Macro, Atlanta, GA. Her toll-free telephone
number is 1-866-368-5657.

Voluntary Assent
I read this form or it has been read to me. I understand what it says. My questions (if any) have been answered. A
copy of this form will be given to me. By signing my name below, I freely agree to participate in this interview.
Participant Printed Name ______________________________________________________________
Participant Signature __________________________________________________________________
Witness________________________________________________________ Date__________________

CMHS National Evaluation
Phase VII February 2011

2 signed forms: 1 for the interview participant and 1 for the interviewer

Attachment E: Sector and Comparison Study

EDUCATION SECTOR AND COMPARISON STUDY
INFORMED ASSENT—YOUTH VERSION
Purpose
The Center for Mental Health Services (CMHS), a center in the Substance Abuse and Mental
Health Services Administration, an agency within the United States Department of Health and
Human Services, is studying system of care programs. The Center for Mental Health Services
(CMHS) wants to know more about educational, mental health, substance use, and other
behavioral services provided to children and their families. They want to know how well these
services work. ICF Macro is conducting a study to learn more about how to make these services
better by talking to children and families in the (agency name/system name).
The person who takes care of you is being asked questions for this study, and may have also
answered questions in the past. Because you are 11 years old, we would like to ask you
questions. You will be able to tell us about yourself and what you think about your services.
Description of Participation
You will have an interview every 6 months. You may have up to five interviews. We can talk
with you in your home or any other place that is best for you. Each interview will take about 1
hour.
You will be asked questions about how you feel. You will be asked about what you do at home,
in school, and in your neighborhood. You will be asked about what you do with your family and
friends. You will be asked about the services you have had. We will still ask to talk to you if you
stop getting services.
We would like you to let us look at your records. These records include your grades, how much
you were absent, and if you were ever in detention. We may also want to look at records about
your services from other agencies where you may have received services. We will also want to
talk to people who work at your school.
Risks and Benefits
You will not get any benefits from being in this study. You may learn new things about yourself.
As a result of this study, services for youth, like the ones you receive, may get better. A risk is
that you may feel uncomfortable about answering questions about yourself. We have taken steps
to protect your privacy.
Compensation
You will receive $20 for each interview you complete, and a $50 bonus at the end of the 24month period if you complete all 5 waves of data collection, to thank you for your time.
Protection of Information
The study team has taken steps to protect your privacy. The information obtained in your
interviews and your record review will be used for this study. Only authorized people will have
access to the information. None of the interview or record review forms that are used in the study

have your name on them. They only have special codes. Papers with your name on them will be
kept in a locked filing cabinet. In reports, your answers will be grouped with those of others. We
will never mention your name. The information obtained in your interviews will be released to
the national evaluation team, consisting of ICF Macro, and our funding agency, the Substance
Abuse and Mental Health Services Administration.
There are two instances when the study team will not be able to keep your information
confidential. If a study team member finds out that you plan to harm yourself or someone else or
if there is alleged or suspected child abuse or neglect, we may report it to local authorities.
Also, we have applied for a Confidentiality Certificate from the Federal government to protect
the people who interview you from being forced, even under a court order or subpoena, to
identify you. The Confidentiality Certificate does not imply that the government has approved or
disapproved of this study. In addition, the Federal agency funding this research may see your
information if it audits us to ensure that the study team protects your rights and safety.
Rights Regarding Decision to Participate
It is completely up to you whether you participate in the study. If you agree to take part in this
study, you can change your mind and quit at any time. If you change your mind and quit, any
information you gave to the study will be destroyed, if this is what you want. If you decide not to
be in this study, it will not affect services for you or your family. You should also know that if
you decide to participate now and later change your mind, you can withdraw from the study at
any time.
Contact Information
If you have any questions about this evaluation study, you can call (Research Coordinator) to
have your questions answered. You can call him/her collect at (555) 555–5555. To contact the
Institutional Review Board that reviewed this study you can call 1-877-556-2218.
Voluntary Assent
I have read this form or, it has been read to me, and I understand what it says. My questions have
been answered. A copy of this form will be given to me.
By signing my name below, I freely agree to the following as indicated by a check in the YES
box.
1. To be interviewed at the beginning of the study and every 6 months thereafter, for up to
24 months.
Yes
No
2. To have a study team member contact my school teacher and head of my school to be
interviewed for the study.
Yes
No

3. To have a study team member access my mental health service records, education
records, juvenile justice records, department of social services and child protection
records, or records from other service providers from which I’ve received services in the
12-months prior to the study and during the course of the study period and the costs of
those services.
Yes
No
Youth’s Name (Type or Print Full Name): ______________________________________
Signature of Youth: ________________________________________________Date: ___/___/____

I, _____________________________________, have read the above. My child may participate.
(Caregiver/Guardian)
Guardian’s Signature: ______________________________________________ Date: ___/___/____

Thank you very much for your help in this important study. The information you give us will
help us enhance services for children and families.

EDUCATION SECTOR AND COMPARISON STUDY
INFORMED CONSENT—YOUNG ADULT VERSION
Purpose
The Center for Mental Health Services (CMHS), a center in the Substance Abuse and Mental
Health Services Administration, an agency within the United States Department of Health and
Human Services, is studying system of care programs. These programs are funded throughout
the country to improve services for children and families. CMHS wants to know more about
these services and how well they work. In order to assess the outcomes of these programs, ICF
Macro is conducting a Sector and Comparison Study. You were invited to participate in this
study because you were eligible to receive educational, mental health, substance use, or other
behavioral services. We would like to know if you would agree to take part in the study we are
doing. In this study, we are interested in finding out about how you feel; what you do at home, in
school, and in the neighborhood; the kinds of services you have received; and how you feel
about these services. The results of the study will be used to help improve the quality of services
for children and families.
Description of Participation
We may interview you up to five times. We will interview you at the beginning of the study.
Then you will be contacted for additional interviews every 6 months for up to 24 months after
that. We will ask you to continue to participate in the study even if you are no longer receiving
services. The interviews will be conducted in your home or any other place that is best for you.
Each interview will take about 1 hour.
You will be asked questions about your behavior at home, in school, and in the community. We
will also ask you questions about your family and your experiences with the services you have
received, including mental health and substance use services.
Administrative Records
As part of the study, we would like your permission to make use of your school records,
including disciplinary, attendance, and transfers, and other records related to services you may
have received (for example, juvenile court records, records from the department of human
services and child protection, mental health services records). Your agreement to participate in
this study and your signature on this form provide your permission for the release of any of these
records. We may also want to ask questions of agency representatives from juvenile court, the
department of human services and child protection, and/or your school.
As part of the study, we will also be interviewing your teacher when enrollment into the study
begins and every 6 months for up to 24 months and a school administrator at your school when
enrollment begins and every 12 months for up to 24 months.
Risks and Benefits
You will not get any benefits from being in this study. A risk is that you may feel uncomfortable
about answering questions about yourself.

Compensation
You will receive $20 for each interview, and a $50 bonus at the end of the 24-month period if
you complete all 5 waves of data collection, to thank you for your time.
Protection of Information
The study team has taken steps to protect your privacy. The information obtained in your
interviews and your record review will be used for this study. Only authorized people will have
access to the information. None of the interview or record review forms that are used in the study
have your name on them. They only have special codes. Papers with your name on them will be
kept in a locked filing cabinet. In reports, your answers will be grouped with those of others. We
will never mention your name. The information obtained in your interviews will be released to
the national evaluation team, consisting of ICF Macro, and our funding agency, the Substance
Abuse and Mental Health Services Administration.
The study team has applied for a Confidentiality Certificate from the Federal government to
protect the people who interview you from being forced, even under a court order or subpoena,
to identify you. The Confidentiality Certificate does not imply that the government has approved
or disapproved of this study. In addition, the Federal agency funding this research may see your
information if it audits us to ensure that the study team protects your rights and safety.
There are two instances when the study team will not be able to keep your information
confidential. If a study team member finds out that you plan to harm yourself or someone else or
if there is alleged or suspected child abuse or neglect, we may report it to local authorities.
Rights Regarding Decision to Participate
It is completely up to you whether you participate in the study. If you agree to take part in this
study, you can change your mind and quit at any time. If you change your mind and quit, any
information you gave to the study will be destroyed, if this is what you want. If you decide not to
be in this study, it will not affect services for you or your. You should also know that if you
decide to participate now and later change your mind, you can withdraw from the study at any
time.
Contact Information
If you have any questions about this evaluation study, you can call (Research Coordinator) to
have your questions answered. You can call him/her collect at (555) 555–5555. To Contact the
Institutional Review Board that reviewed this study, call 1-877-556-2218.
Voluntary Consent
I have read this form or, it has been read to me, and I understand what it says. My questions have
been answered. A copy of this form will be given to me.
By signing my name below, I freely agree to the following as indicated by a check in the YES
box.
1. To be interviewed at the beginning of the study and every 6 months thereafter, for up to
24 months.

Yes
No
2. To have a study team member contact my school teacher and a school administrator to be
interviewed for the study.
Yes
No
3. To have a study team member access my mental health service records, education
records, juvenile justice records, department of social services and child protection
records, or records from other service providers from which I’ve received services in the
12-months prior to the study and during the course of the study period and the costs of
those services.
Yes
No
Young Adult’s Name (Type or Print Full Name): ______________________________________
Signature of Young Adult: _________________________________________________________
Date: ___/___/____

Thank you very much for your help in this important study. The information you give us will
help us enhance services for children and families.

JUVENILE JUSTICE SECTOR AND COMPARISON
STUDY
INFORMED ASSENT—YOUTH VERSION
Purpose
The Center for Mental Health Services (CMHS), a center in the Substance Abuse and Mental
Health Services Administration, an agency within the United States Department of Health and
Human Services, is studying system of care programs. wants to know more about educational,
mental health, substance use, and other behavioral services provided to children and their
families. They want to know how well these services work. ICF Macro and EMSTAR Research,
a local evaluator in Georgia, are working together on a study to learn more about how to make
these services better by talking to children and families in the (agency name/system name).
The person who takes care of you is being asked questions for this study, and may have also
answered questions in the past. Because you are 11 years old, we would like to ask you
questions. You will be able to tell us about yourself and what you think about your services.
Description of Participation
You will have an interview every 6 months. You may have up to five interviews. We can talk
with you in your home or any other place that is best for you. Each interview will take about 1
hour.
You will be asked questions about how you feel. You will be asked about what you do at home,
in school, and in your neighborhood. You will be asked about what you do with your family and
friends. You will be asked about the services you have had. We will still ask to talk to you if you
stop getting services.
We would like you to let us look at your records. These records include your grades, how much
you were absent, and if you were ever in detention. We may also want to look at records about
your services from other agencies where you may have received services. We will also want to
talk to people who work for the Department of Juvenile Justice or the Juvenile Court.
Risks and Benefits
You will not get any benefits from being in this study. You may learn new things about yourself.
As a result of this study, services for youth, like the ones you receive, may get better. A risk is
that you may feel uncomfortable about answering questions about yourself. We have taken steps
to protect your privacy.
Compensation
You will receive $20 for each interview, and a $50 bonus at the end of the 24-month period if
you complete all 5 waves of data collection, to thank you for your time.

Protection of Information
The study team has taken steps to protect your privacy. The information obtained in your
interviews and your record review will be used for this study. Only authorized people will have
access to the information. None of the interview or record review forms that are used in the study
have your name on them. They only have special codes. Papers with your name on them will be
kept in a locked filing cabinet. In reports, your answers will be grouped with those of others. We
will never mention your name. The information obtained in your interviews will be released to
the national evaluation team, consisting of ICF Macro, and our funding agency, the Substance
Abuse and Mental Health Services Administration, and EMSTAR Research (local system of care
evaluator).
There are two instances when the study team will not be able to keep your information
confidential. If a study team member finds out that you plan to harm yourself or someone else or
if there is alleged or suspected child abuse or neglect, we may report it to local authorities.
Also, we have applied for a Confidentiality Certificate from the Federal government to protect
the people who interview you from being forced, even under a court order or subpoena, to
identify you. The Confidentiality Certificate does not imply that the government has approved or
disapproved of this study. In addition, the Federal agency funding this research may see your
information if it audits us to ensure that the study team protects your rights and safety.
Rights Regarding Decision to Participate
It is completely up to you whether you participate in the study. If you agree to take part in this
study, you can change your mind and quit at any time. If you change your mind and quit, any
information you gave to the study will be destroyed, if this is what you want. If you decide not to
be in this study, it will not affect services for you or your family. You should also know that if
you decide to participate now and later change your mind, you can withdraw from the study at
any time.
Contact Information
If you have any questions about this evaluation study, you can call (Research Coordinator) to
have your questions answered. You can call him/her collect at (555) 555–5555. To contact the
Institutional Review Board that reviewed this study you can call 1-877-556-2218.
Voluntary Assent
I have read this form or, it has been read to me, and I understand what it says. My questions have
been answered. A copy of this form will be given to me. By signing my name below, I freely
agree to the following as indicated by a check in the YES box.
1. To be interviewed at the beginning of the study and every 6 months thereafter, for up to
24 months.
Yes
No
2. To have a study team member contact my court representative.
Yes

No
3. To have a study team member access my mental health service records, education
records, juvenile justice records, department of social services and child protection
records, or records from other service providers from which I’ve received services in the
12-months prior to the study and during the course of the study period and the costs of
those services.
Yes
No

Youth’s Name (Type or Print Full Name): ______________________________________
Signature of Youth: ________________________________________________Date: ___/___/____

I, _____________________________________, have read the above. My child may participate.
(Caregiver/Guardian)
Guardian’s Signature: ______________________________________________ Date: ___/___/____

Thank you very much for your help in this important study. The information you give us will
help us enhance services for children and families.

JUVENILE JUSTICE SECTOR AND COMPARISON
STUDY
INFORMED CONSENT—YOUNG ADULT VERSION
Purpose
The Center for Mental Health Services (CMHS), a center in the Substance Abuse and Mental
Health Services Administration, an agency within the United States Department of Health and
Human Services, is studying system of care programs.. These programs are funded throughout
the country to improve services for children and families. CMHS wants to know more about
these services and how well they work. In order to assess the outcomes of these programs, ICF
Macro is conducting a Sector and Comparison Study in collaboration with EMSTAR Research, a
local evaluator in Georgia. You were invited to participate in this study because you were
eligible to receive educational, mental health, substance use, or other behavioral services. We
would like to know if you would agree to take part in the study we are doing. In this study, we
are interested in finding out about how you feel; what you do at home, in school, and in the
neighborhood; the kinds of services you have received; and how you feel about these services.
The results of the study will be used to help improve the quality of services for children and
families.
Description of Participation
We may interview you up to five times. We will interview you at the beginning of the study.
Then you will be contacted for additional interviews every 6 months for up to 24 months after
that. We will ask you to continue to participate in the study even if you are no longer receiving
services. The interviews will be conducted in your home or any other place that is best for you.
Each interview will take about 1 hour.
You will be asked questions about your behavior at home, in school, and in the community. We
will also ask you questions about your family and your experiences with the services you have
received, including mental health and substance use services.
Administrative Records
As part of the study, we would like your permission to make use of your school records,
including disciplinary, attendance, and transfers, and other records related to services you may
have received (for example, juvenile court records, records from the department of human
services and child protection, mental health services records). Your agreement to participate in
this study and your signature on this form provide your permission for the release of any of these
records. We may also want to ask questions of agency representatives from juvenile court, the
department of human services and child protection, and/or your school.
We will also be interviewing a juvenile court representative, who could be your probation
officer, case worker, or other juvenile court personnel most closely associated with your
involvement with the juvenile justice system, when enrollment begins and every 6 months for up
to 24 months.

Risks and Benefits
You will not get any benefits from being in this study. A risk is that you may feel uncomfortable
about answering questions about yourself.
Compensation
You will receive $20 for each interview, and a $50 bonus at the end of the 24-month period if
you complete all 5 waves of data collection, to thank you for your time.
Protection of Information
The study team has taken steps to protect your privacy. The information obtained in your
interviews and your record review will be used for this study. Only authorized people will have
access to the information. None of the interview or record review forms that are used in the study
have your name on them. They only have special codes. Papers with your name on them will be
kept in a locked filing cabinet. In reports, your answers will be grouped with those of others. We
will never mention your name. The information obtained in your interviews will be released to
the national evaluation team, consisting of ICF Macro, our funding agency, the Substance Abuse
and Mental Health Services Administration, and EMSTAR Research (local system of care
evaluator).
The study team has applied for a Confidentiality Certificate from the Federal government to
protect the people who interview you from being forced, even under a court order or subpoena,
to identify you. The Confidentiality Certificate does not imply that the government has approved
or disapproved of this study. In addition, the Federal agency funding this research may see your
information if it audits us to ensure that the study team protects your rights and safety.
There are two instances when the study team will not be able to keep your information
confidential. If a study team member finds out that you plan to harm yourself or someone else or
if there is alleged or suspected child abuse or neglect, we may report it to local authorities.
Rights Regarding Decision to Participate
It is completely up to you whether you participate in the study. If you agree to take part in this
study, you can change your mind and quit at any time. If you change your mind and quit, any
information you gave to the study will be destroyed, if this is what you want. If you decide not to
be in this study, it will not affect services for you or your family. You should also know that if
you decide to participate now and later change your mind, you can withdraw from the study at
any time.
Contact Information
If you have any questions about this evaluation study, you can call (Research Coordinator) to
have your questions answered. You can call him/her collect at (555) 555–5555. To contact the
Institutional Review Board that reviewed this study call 1-877-556-2218.
Voluntary Consent
I have read this form or, it has been read to me, and I understand what it says. My questions have
been answered. A copy of this form will be given to me.

By signing my name below, I freely agree to the following as indicated by a check in the YES
box.
1. To be interviewed at the beginning of the study and every 6 months thereafter, for up to
24 months.
Yes
No
2. To have a study team member contact my court representative.
Yes
No
3. To have a study team member access my mental health service records, education
records, juvenile justice records, department of social services and child protection
records, or records from other service providers from which I’ve received services in the
12-months prior to the study and during the course of the study period and the costs of
those services.
Yes
No
Young Adult’s Name (Type or Print Full Name): ______________________________________
Signature of Young Adult: ________________________________________
Date: ___/___/____
Thank you very much for your help in this important study. The information you give us will
help us enhance services for children and families.

Attachment G: Consent Letters for Longitudinal Child and Family Outcome Study
and Service Experience Study

SAMPLE INFORMED ASSENT—YOUTH VERSION
(Suggested Content and Wording)

Key Components of a Consent Form
Elements to Include:
Purpose of the Study
 Funding source
 Local system of care name
 Description of why the study will
be conducted

Description of Participation
 Participant responsibilities
 Description of data collection
methods: interviews--frequency,
duration; record review;
observation, etc.
 Other guidelines (e.g., possible
data sources, age, changes in
participation over time, etc.)

Risks and Benefits
 Potential risk factors associated
with participation
 Potential benefits that may be
gained through participation

Compensation for Participation
 Type and amount of
compensation participant will
receive for participation

Contact Information
 Contact information for
someone working on the study
who will be available to answer
participant questions

Purpose
The (system of care name) in your community provides services
to children and families. The Center for Mental Health Services,
within the Substance Abuse and Mental Health Services
Administration of the Federal government wants to know more
about these services. They want to know how well these services
work. The National Evaluation Team is talking to children and
families in the (system of care name) to learn more about how to
make these services better.
The person who takes care of you has been asked questions for
this project in the past. Because you are now 11 years old, we
would like to ask you questions. You will be able to tell us about
yourself and what you think about the services you have received.

Description of Participation
You will have an interview every 6 months. You may have up to five
interviews. You may have fewer interviews, depending upon when
you started services. We can talk with you in your home or any
other place that is best for you. Each interview will take about 1
hour.
You will be asked questions about how you feel. You will be asked
about what you do at home, in school, and in your neighborhood.
You will be asked about what you do with your family and friends.
You will be asked about the services you have had. We will still ask
to talk to you if you stop getting services.
We would like you to let us look at your school records. These
records include your grades, how much you were absent, and if you
were ever in detention. We want to look at court records and
records about your services. We may also want to talk to people
who work for the court or your school.

Risks and Benefits
You will not get any benefits from being in this project. A risk is that
you may feel uncomfortable about answering questions about
yourself.

Compensation
You will receive $XX for each interview to thank you for your time.

Contact Information
If you have any questions about this evaluation project, you can call
(evaluator) to have your questions answered. You can call him/her
collect at (555) 555-5555. To contact the Institutional Review Board
that reviewed this project, call (555) 555-5555.

Continued on next page

Sample Informed Assent—Youth Version

| Page 1 of 2 | April 2011

Key Components of a Consent Form
Protection of Information
 Protocol for maintaining participant
privacy
 Mandated reporting requirements
 Description and purpose of the
Federal Certificate of Confidentiality
Rights Regarding Decision to Participate
 Statement of participant rights to
terminate participation at will
 Statement that the termination of
participation will not lead to adverse
consequences
Voluntary Assent
 Statement of participant
understanding of the assent form
 Statement that participant has had all
of his or her questions answered
 Permission to be interviewed
 Permission to access service provider
records for 12 months previous to
service and 24 months after the first
service
 Signature line for participant to sign,
thus assenting to participate
 Signature line for guardian signature
 Date

Protection of Information
Anything we learn about you will be kept as secret as possible.
We have taken steps to protect your privacy. None of the
information for this study will have your name on it. It will have
only special codes. Papers with your name on them will be
kept in a locked filing cabinet. In reports, your information will
be grouped together with information from others. We will
never mention your name. Only approved people will be able to
see your information. The information will be shared with the
agency that pays for this study, companies that work for them,
and other places that provide services to you.
There are some times when we cannot promise to keep your
name secret. If you tell the person who interviews you that you
plan to hurt yourself or someone else, then she/he [will/may]
have to tell a doctor or some other authority so that you can get
help. Interviewers must obey State laws and report certain
kinds of diseases that other people can catch. And they must
report child abuse.

Also, we have applied for a Certificate of Confidentiality from
the Federal government to protect the people who interview
you from being forced, even under a court order or subpoena,
to identify you. An exception to privacy is if we learn about child
abuse or neglect or if you tell the person who interviews you
that you plan to harm yourself or someone else, then he/she
will tell a doctor or some other authority so that you can get
help. Interviewers may report child abuse. In addition, the
Federal agency funding this research may see your information if it audits us. The Certificate of
Confidentiality does not imply that the government has approved or disapproved of this project.

Rights Regarding Decision to Participate
I understand that I will not be in trouble if I do not want to be in the study or if I decide to quit later. I do not
have to answer questions that I do not want to answer. If I change my mind and quit, all of my answers to
questions will be destroyed, if that is what I want. No one will say that I can’t be in other projects because
I don’t want to be in this project. No one can say that I cannot get services because I don’t want to be in
this project.

Voluntary Assent
I read this form, or it has been read to me, and I understand what it says. My questions (if any) have been
answered. A copy of this form will be given to me. By signing my name below, I freely agree:
 to be interviewed every 6 months, for up to 24 months

____

 to have the project access my mental health records,
Past 12 Months Next 24 Months
education records, juvenile justice records, department of
social services and child protection records, or service records
____
____
from other services coordinated through (system of care name)
Youth’s Name (Type or Print Full Name): ______________________________________
Signature of Youth: ________________________________________

Date: ___/___/____

I, _____________________________________, have read the above. My child may participate.
(Caregiver/Guardian)
Guardian’s Signature: ______________________________________
Sample Informed Assent—Youth Version

Date: ___/___/____

| Page 2 of 2 | April 2011

SAMPLE INFORMED CONSENT—YOUNG ADULT VERSION
(Suggested Content and Wording)

Components of a Consent Form
Elements to include:
Purpose of the Study
 Funding source
 Local program name
 Description of why the study will
be conducted

Description of Participation
 Participant responsibilities
 Description of data collection
methods: interviews--frequency,
duration; record review;
observation, etc.
 Other guidelines (e.g., possible
data sources, age, changes in
participation over time, etc.)

Risks and Benefits
 Potential risk factors associated
with participation
 Potential benefits that may be
gained through participation

Compensation for Participation
 Type and amount of
compensation participant will
receive for participation

Purpose
The Center for Mental Health Services in the United States Department
of Health and Human Services is sponsoring a national evaluation of
programs that are funded by the Substance Abuse and Mental Health
Services Administration to improve community-based mental health
services for children and families. You were invited to participate in this
project because you received such services. At that time, your family
agreed to participate in the project we are doing. Now that you are 18
and a legal adult, we need to ask you again if you would like to
continue participation in the project. In this project, we are interested in
finding out about how you feel; what you do at home, in school, and in
the neighborhood; the kinds of services you have received; and how
you feel about these services. The results of the project will be used to
help improve the quality of services for children and families. The
national evaluation is authorized by Section 565 of the Public Health
Service Act.

Description of Participation
We will interview you up to five times depending upon whether you
entered the study at the beginning or toward the end. Participation
includes follow-up interviews every 6 months while you are in the
evaluation. We will ask you to continue to participate in the project
even if you do not receive services any longer. The interviews will be
conducted in your home or any other place that is convenient for you.
Each visit will take about 1 hour.
You will be asked questions about your behavior at home, in school,
and in the community. We will also ask you questions about your family
and your experiences with the services you have received, including
mental health and substance use services.

As part of the project, we would like your permission to make use of
your school records, including disciplinary, attendance, and transfers,
and other records related to services you may have received (for
Contact Information
example, juvenile court records, records from the department of human
 Contact information for
services and child protection, mental health services records). Your
someone working on the study
agreement to participate in this project and your signature on this form
who will be available to answer
provide your permission for the release of any of these records. We
participant questions
may also want to ask questions of agency representatives from
juvenile court, the department of human services and child protection, and/or your school.

Risks and Benefits
You will not get any benefits from being in this project. A risk is that you may feel uncomfortable about
answering questions about yourself.

Compensation
You will receive $XX for each interview to thank you for your time.

Contact Information
If you have any questions about this evaluation project, you can call (evaluator) to have your questions
answered. You can call him/her collect at (555) 555-5555. To contact the Institutional Review Board that
reviewed this project, call (555) 555-5555.

Continued on next page
Informed Consent—Young Adult Version

| Page 1 of 2 | April 2011

Components of a Consent Form
Protection of Information
 Protocol for maintaining participant
privacy
 Mandated reporting requirements
 Description and purpose of the
Federal Certificate of Confidentiality

Rights Regarding Decision to Participate
 Statement of participant rights to
terminate participation at will
 Statement that the termination of
participation will not lead to adverse
consequences

Voluntary Consent
 Statement of participant
understanding of the consent form
 Statement that participant has had all
of his or her questions answered
 Permission to be interviewed
 Permission to access service provider
records for 12 months previous to
service and 24 months after the first
service
 Signature line for participant to sign,
thus assenting to participate
 Signature line for guardian signature
 Date

Protection of Information
Anything we learn about you will be kept as secret as
possible. We have taken steps to protect your privacy. None of
the information for this study will have your name on it. It will
have only special codes. Papers with your name on them will
be kept in a locked filing cabinet. In reports, your information
will be grouped together with information from others. We will
never mention your name. Only approved people will be able
to see your information. The information will be shared with
the agency that pays for this study, companies that work for
them, and other places that provide services to you.
There are some times when we cannot promise to keep your
name secret. If you tell the person who interviews you that you
plan to hurt yourself or someone else, then she/he [may/will]
have to tell a doctor or some other authority so that you can
get help. Interviewers must obey State laws and report certain
kinds of diseases that other people can catch. And they must
report child abuse.
Also, we have applied for a Certificate of Confidentiality from
the Federal government to protect the people who interview
you from being forced, even under a court order or subpoena,
to identify you. An exception to privacy is if we learn about
child abuse or neglect or if you tell the person who interviews
you that you plan to harm yourself or someone else, then
he/she will tell a doctor or some other authority so that you can
get help. Interviewers may report child abuse. In addition, the
Federal agency funding this research may see your
information if it audits us. The Certificate of Confidentiality
does not imply that the government has approved or
disapproved of this project.

Rights Regarding Decision to Participate
I understand that I will not be in trouble if I do not want to be in the study or if I decide to quit later. I do not
have to answer questions that I do not want to answer. If I change my mind and quit, all of my answers to
questions will be destroyed, if that is what I want. No one will say that I can’t be in other projects because
I don’t want to be in this project. No one can say that I cannot get services because I don’t want to be in
this project.

Voluntary Consent
I read this form or it has been read to me. I understand what it says. My questions (if any) have been
answered. A copy of this form will be given to me. By signing my name below, I freely agree:
 to be interviewed every 6 months, for up to 24 months

____

 to have the project access my mental health records,
Past 12 Months Next 24 Months
education records, juvenile justice records, department of
social services and child protection records, or service records
____
____
from other services coordinated through (system of care name)
Young Adult’s Name (Type or Print Full Name): ______________________________________
Signature of Young Adult:
________________________________________
Date: ___/___/____
Informed Consent—Young Adult Version

| Page 2 of 2 | April 2011