Form Client Follow-up C Client Follow-up C Client Follow-up Consent Script

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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 10 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 Caller Follow-up Consent Script
Telephone Consent Script for Follow-up Telephone Assessment
Briefly introduce yourself and explain the purpose of your call. Remind the client that when he/she
received a follow-up call from (name of crisis center) he/she said it would be okay for us to call him/her to
see if he/she might be interested in participating in a research study involving a follow-up telephone
assessment: Ask the client if he/she feels well enough to talk at this time.
Read the following to the client:
I would like to explain what this research survey is about. You can interrupt with questions at any time.
_________________ (name of crisis center) is working with Columbia University researchers at the New
York State Psychiatric Institute (NYSPI) on a research study that is sponsored by a federal agency, the
Substance Abuse and Mental Health Services Administration. We are doing this follow-up telephone
assessment because it will help us find out whether crisis hotlines provide effective services to the people
they follow-up with. The purposes of this call are to find out how you have been doing since you received
a call from _________________ (name of crisis center), and to ask your permission to access
information about your circumstances at the time you were referred to them.
During this survey, we will ask you some questions to find out what you were going through when you
were referred for follow-up from the crisis hotline on ______________ (date of referral for follow-up), how
you have been feeling since you spoke with them, and how you are feeling now. We will ask you about
the referral(s) that the crisis hotline counselor gave to you, and whether you've been able to follow up
with the referral(s). We will also ask you whether you have accessed any other resource for help either
before or after you spoke with the crisis counselor.
The only foreseeable discomfort you might experience while answering the survey questions, is that you
may think about the concern that prompted you to accept follow-up from the crisis line and any emotional
problems you may have, and you may feel the need to talk about your concern some more. I am not an
employee of the crisis service, but I am a trained crisis worker and can suspend the interview and
discuss your concern with you. After this, you may decide to continue the interview, postpone it to
another time, or decide not to complete it.
The benefits of participating in the follow-up call may include the opportunity for you to discuss how you
have been doing since your contact with the crisis center, or to clarify the plan that you and the counselor
came up with. Your responses can help improve the quality of services offered by the crisis hotline.
Taking part in the study is voluntary. You can refuse to answer any or all of the questions. You can stop
at any time. You would not be penalized in any way if you did not want to answer any questions or
decided to stop participating in the survey.
If you participate in the telephone research assessment, we will schedule the survey at a time that is
good for you. We can do it right now, if this is a convenient time for you. The assessment will take
approximately 30 to 40 minutes. We will send you $50 to thank you for taking the time to talk with us. We
will mail you a money order soon after you have finished the survey. It will take about two to three weeks
for you to receive the money order.
Before I discuss privacy, do you have any questions about what I have said so far?
We are very concerned about keeping your answers private. We will not put your name on the survey. It

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will refer to you only by a study number. Data in our computers will contain only this number, not your
name. Be assured that neither you, nor anyone else taking part in the study will be identified by name in
any publication or report of the findings. All of our project staff have signed a confidentiality statement
saying that they will keep your answers private and taken training related to the privacy and security of
information collected for this research. NYSPI is a health care institution subject to the Health Insurance
Portability and Accountability Act (HIPAA). Our project staff will be the only people who can link your
study number with your name.

All records that link your name with your study number will be kept in locked files in our offices at the
New York State Psychiatric Institute (NYSPI) and will be kept confidential to the extent permitted by law.
However, if we learn about serious harm to you or someone else, as in cases of abuse, we would have to
take whatever measures are needed to protect the individuals involved, including reporting to appropriate
protective services. Other kinds of problems are thoughts about killing yourself or doing things to cause
serious harm to yourself on purpose. In these kinds of situations, we would be obligated to refer you back
to the hotline for intervention. This would involve our contacting the hotline to immediately implement
their routine procedures for handling emergencies.
If you have any questions or concerns about any aspect of the project, you may call the Principal
Investigator Dr. Madelyn S. Gould, or the Project Director Ms. Jimmie Lou Harris at 212-543-5329 and
212-543-5482 respectively. If you have any questions about your rights as a research subject or any
complaints, you may call our Institutional Review Board (IRB) at 212-543-5758.
Do you have any questions? Are you willing to take part in the telephone research survey? I will be
turning on a tape recorder to record your answer about agreeing to participate.
___________________________ (Subject’s name), do you agree to take part in the telephone research
assessment for the Hotline Follow-up Evaluation Study?
Agreed_________ Refused_________ Date__________________________________

Do you agree to have us link this interview with information about the circumstances of your accepting
follow-up from the center? This information will include an assessment of your risk status at that time.
Agreed_________ Refused_________ Date__________________________________
Note to Interviewer: If caller answers “No” to either of the above, please ask the following:
Unless you object, we would still like to access information about your risk status at the time you
accepted follow-up from the center for the purpose of generating general, statistical knowledge about
hotline clients. This information will not identify you in any way. Do you agree to allow us to use this
information in this way?
Agreed_________ Refused_________ Date__________________________________

IF THIS INTERVIEW WAS SELECTED FOR TAPING, please also obtain the consent for taping below:
In order to keep track of the quality of the survey, we would like to tape record the survey with you. No
information that can identify you will be on the tapes. The tapes will be erased at the end of the project. If
you say “no,” you can still take part in the research survey and you will still receive $50. Do you agree to
let me tape this survey?
Agreed__________ Refused________ Date____________________________________

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SIGNATURE:

_____________________________________

___________________________________

Signature of Person Obtaining Consent

Printed Name of Person Obtaining Consent