Form Counselor Consent Counselor Consent Counselor Consent

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OMB No. 0930-0274
Expiration Date: XX/XX/2016
Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number. The OMB control number for this project is 0930-0274. Public
reporting burden for this collection of information is estimated to average 5 minutes per client per year, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing
the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 2-1057,
Rockville, Maryland, 20857.

MI/SP Counselor Consent
Purpose of the Research
This research project, funded by the Substance Abuse and Mental Health Services
Administration (SAMHSA), has been designed to evaluate SAMHSA's cooperative initiative with
the National Suicide Prevention Lifeline (NSPL) to provide follow-up to suicidal hotline callers
and at-risk individuals discharged from hospital emergency rooms and inpatient units. As part of
this initiative, telephone crisis counselors at twelve centers in the NSPL network will receive
training incorporating recent advances in motivational interviewing and safety planning (Safety
Planning Intervention training, or SPI). The training is not part of the research study; however,
the study will examine the impact of the training on the crisis counseling process and outcome.
Your center has been selected by SAMHSA to be one of the twelve centers that are part of this
research.
What the Study Involves
In the course of the study, you will be asked to complete either one or two types of selfadministered questionnaire. First, you will be asked to complete a questionnaire upon
completion of SPI training. This questionnaire will include questions about how prepared you
feel to use SPI procedures with clients, and whether you feel the training will improve the
services you provide to clients. It will also ask about your prior training, level of education, and
experience as a telephone crisis counselor. Part II of this questionnaire will ask for your
feedback on SPI once you have had the opportunity to implement the intervention with suicidal
clients. Next, if you are responsible for conducting follow-up calls at your center, you will also be
asked to complete a questionnaire for each client you attempt to follow. This questionnaire asks
about the circumstances of the client’s referral for your follow-up, whether contact is
successfully made with the client, any safety plan you develop with the client, any additional
treatment referrals you offer the client, to what extent the client follows through with referrals,
and how the client is doing at the time of follow-up.
Privacy
We are very concerned about maintaining your privacy. For the purpose of linking your
questionnaires, your name and the name of your center will be recorded on questionnaires
temporarily. When we receive your questionnaires – by mail or fax – we will delete your name
and the name of your center and refer to you and your center only by study numbers. Data in
our computers will contain only study numbers, not any names or pseudonyms. Only group data
that has no identifying information will be presented at meetings or in reports.
All records will be stored in locked files in our offices at Columbia University and will be kept
confidential to the extent permitted by law. Records will only be available to research staff,
Federal and State and Institutional regulatory personnel who may review records as part of
routine audits. We will destroy the records at the end of the project.
Risks
No risks are anticipated from participating in this research. A breach of confidentiality is
possible, but as we described above, we have taken precautions to minimize this risk.

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Benefits
This study is not designed for the benefit of any individual. However, your center may request
reports and follow up consultation from the researchers that can inform and enhance your
services to individuals in crisis. Again, no individual counselor or client will be identified in these
reports. Providing independent evaluation data to potential funding sources may enhance your
center’s ability to obtain funding and sustain its critical services. Furthermore, it is hoped that the
study will provide a broader benefit to society. Previous research shows that seriously suicidal
individuals call crisis hotlines, and that calls to crisis hotlines are associated with reductions in
crisis and suicidal states. This study is designed to help optimize telephone crisis services as a
suicide prevention strategy by evaluating how training of crisis counselors, and follow-up with
suicidal clients, may improve client outcomes. In the long run, such findings may encourage
federal and non-profit investment in the most effective crisis line services.
Research standards and rights of participants
Taking part in the study is up to you. There will be no penalty if you do not want to take part in
the study. You are free to withdraw from this study at any time with no consequence to you by
calling the study Principal Investigator (contact information is provided below).
The researchers will answer to the best of their ability any questions that you may have now or
in the future about this study and your participation in it. If you have any questions or concerns
about any aspect of the project, you may call the Principal Investigator Dr. Madelyn Gould at
(212) 543-5329.
The Institutional Review Board of the New York State Psychiatric Institute-Columbia University
Department of Psychiatry (NYSPI-IRB) has approved the recruitment of subjects for this study,
as indicated by the stamp at the bottom of the form. If you have any questions about your rights
as a research participant or any complaints, you may call the NYSPI-IRB Administrative Director
at (212) 543-5758.

I voluntarily agree to participate in the research study described above.
Print Name_____________________________________________
Signature_______________________________________________Date__________________

I have discussed the proposed research with this participant, and, in my opinion, this participant
understands the benefits, risks and alternative (including non-participation) and is capable of
freely consenting to participate in this research.
Print Name_____________________________________________
Signature_______________________________________________Date__________________