Consent Form for Client Focus Group

ATTACHMENT K

consent form for client focus group

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Focus Group Consent Form

Thank you for your interest in participating in a focus group for the Evaluation of the Primary and Behavioral Health Care Integration (PBHCI) Program. Please read through the following information and, if you agree to participate, fill in the information at the bottom of the form.

What is the Evaluation of the Primary and Behavioral Health Care Integration (PBHCI) Program?

It is a study to learn if access to basic medical services (primary care services) in community mental health centers improves the health of the people they serve. We want to learn whether or not delivering physical health services in community mental health centers improves health conditions such as high blood pressure, obesity, tobacco use, cholesterol, and diabetes. Information collected from you will help researchers and health care providers better understand the health care needs of people who receive services from community mental health centers.

Who can participate in the focus group?

Participants must be 18 years of age or older and enrolled in the PBHCI services from a community mental health center participating in the study.

What does it mean to participate in the focus group?

As a part of the focus group, which will include about 8-10 individuals like yourself, you will be asked to share your experiences receiving care at the community mental health center and other places in the community.

How will the study use your information?

The study team will use your information for research purposes only. The team will follow strict rules to protect your privacy. Your information will be kept private and confidential. Your name will never be used in any report written about the study. To help protect your privacy, the study has a Confidentiality Certificate from the U.S. government. It says we do not have to identify you, even under a court order or subpoena. Please keep in mind: This certificate does not mean the government approves or disapproves of the study. Also, the study team will have to report your information if you tell us that you or someone else is in danger.

What are the benefits of participating in the study?

• You will have the opportunity to share you thoughts and feelings on the services you receive and the care and services you receive.

• As a thank you for your participation, you will receive a $25 gift card to [insert store name] at the end of the focus group meeting.

Do I have to be in the focus group?

No, your participation is completely voluntary. If you decide not to participate, it will not affect your relationship with your community mental health center, your care team or your right to health care benefits that you may be entitled to. If you decide to participate, you can refuse to answer any questions and you can end your participation at any time. Ending your participation will not affect your future care at your community mental health center or anywhere you receive health care. Remember, you will receive a $25 gift card in appreciation for your time.

What if I Have Questions About this Study?

If you have any questions about the focus group or what you will be asked to do, you can ask a member of your care team or the evaluation project director, Jonathan Brown, at 202-484-9220.

Statement

• I have read this form and understand the information presented.

• I agree to participate in the Evaluation of Primary and Behavioral Health Care Integration (PBHCI) Program focus group.

• I know it is my choice whether to participate in the focus group.

• I am at least 18 years of age.

• I understand I can drop out of the focus group at any time.

• I know that the study team will follow strict rules to protect my privacy. My name will never appear in any public document.

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Participant name (print)

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Participant signature

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Date