Example of an Informed Consent Form

CONNECTICUT DEPARTMENT OF MENTAL HEALTH AND ADDICTION SERVICES

HARTFORD WOMEN’S TRAUMA AND SUPPORT DIVERSION PROGRAM

INFORMED CONSENT

Invitation to Participate and Description of Project: You are being invited to take part in a research study of a federally funded program serving women in the criminal justice system. We are asking you because you are in the programs we are studying, [program name:] ___________________________. You do not have to be part of the study to stay in this program, or to get any other services you may be getting for mental health, substance abuse, or housing. We want to make sure you understand that agreeing to be part of the study does not affect your legal situation in any way; it does not help you, and it does not hurt you. Before agreeing to be part of this study, please read and/or listen to the following information carefully and feel free to ask your case manager, treatment staff, or the interviewer any questions you might have.

Description of Procedures: If you decide to be in this study, you will be asked to participate in three research interviews. The first one is today, and the others are six and twelve months from now. These interviews will last about 45 minutes. The interviews will include questions about you and your family and your current and past housing, past problems you may have had, and how your life is going in terms of living situation, health, activities, mental health, substance use, and treatment. The interviews will take place in a location convenient to you, in court, at a treatment facility, other program, your home, or elsewhere. Also, we will ask you for permission to get information from court, from correction, and from the Department of Mental Health and Addiction Services, but we will not talk to them unless you sign a separate form.

If you are in jail during the year that you are in the study, we will ask you to sign another consent form. At this time you can let us know if you want to be interviewed while you are in jail. The interviews will take place in meeting areas at the jail set aside for professional visitors.

Risks and Inconveniences: There is a possibility that some of the questions in the interviews may make you feel uncomfortable. If this happens, we can do any of the following: You can choose not to answer certain questions. You can take a break and continue later. You can choose to stop the interview. If you wish, we can call your clinician, another staff member or concerned others to make sure you have someone to talk with about your feelings. However, when people are in jail, mental health services are not always immediately available.

There is also a small possibility that staff may reveal information to someone who should not have it. However, the staff are carefully trained not to do this, and all staff members are told that they will be fired from their jobs if they ever reveal information that they are not supposed to reveal.

Benefits: This study is not being done to help you, personally. You should know that being in this study will not help you with any criminal charges you may have or with your legal status. What we learn from you may help others in the future by making services and programs better.

Financial Considerations: You are helping us by participating in the study. You will receive $15 for each interview. Also, after the first interview you will get a bonus payment of $5 if you come to the first scheduled appointment. The most you can earn from being in the study is $55. However, if you go to jail, we cannot pay you while you are in jail. You can arrange to pick up interview payments at our office after you are released. Or, after you are released, you can arrange to have your research interviewer bring you the money to you next scheduled appointment.

Confidentiality: The research team will keep any information you give us confidential, and we will not share it with anyone outside of the research team, with certain exceptions. To help keep information about you private and confidential, we have a Confidentiality Certificate from the federal agency giving us money for the study, the Department of Health and Human Services (DHHS). This Certificate does not imply that the Secretary of DHHS approves or disapproves of the project. This Certificate will protect the researchers from being forced to give information about you to others, even under a court order or subpoena. Even with a Confidentiality Certificate, however, there are some times we have to give other people your information. We may report it if we believe that a child or elderly person is at risk of being harmed. Also, if you tell us you are going to physically hurt yourself or someone else, we may contact someone who can help. There is also a possibility that the agency giving us money for this study (DHHS) will want to do an audit, that is, check to see if we are using the grant money the right way. If they do an audit, we have to let them see any files they need, including files that contain your information. Also, you can give permission to let people know that you are in the study.

Voluntary Participation: Your participation in this study is entirely voluntary. Refusal to participate in any part of the study will not affect the services that you are receiving now or in the future. You can stop being in the study at any time without affecting your treatment or other services. Also, if you refuse, it will not make any difference in your court case, or your privileges in jail, if you should go to jail. It will also not help you to get out of jail sooner.

Questions: Please feel free to ask any questions about anything that seems unclear to you and to consider this research and consent form carefully before you sign.

AUTHORIZATION

Please read the following statement: I have read or listened to the information on this consent form, and I understand what is being asked of me. I understand that I will be asked to talk about things like mental health, housing, substance use, and past trauma. I further understand that if I refuse to grant consent, or if I decide to drop out, I still have the same rights to services as I always had.

I have decided that I will be in this project. My signature below also indicates that I have received a copy of this consent form.

Signature of participant

Name (please print) Date

Signature of Conservator, if applicable_________________________________________

Name (please print) Date_______________

Signature of person obtaining consent

Name (please print) Date

You can ask questions of Research Division staff about this project at any time. You can also contact Linda Frisman, Ph.D., the head of this project, at any time to ask questions about the research or if you have a complaint about the study. Her phone number at the Connecticut Department of Mental Health and Addiction Services is 860-418-6788. You may also contact Karen A. Kangas, Director of Patients Rights, Connecticut Department of Mental Health and Addiction Services at 1-800-446-7348, if you feel that you have been treated unfairly in any way relating to this study or have any complaints or questions regarding your rights as a participant in this study.