I understand that I am volunteering to take part in a study that will explore the therapy experiences of African American and Caucasian biracial individuals. The goal of this study is to gather information regarding the experience of therapy, with particular focus on biracial identity issues and perceptions of the therapist's knowledge and understanding of biracial issues.
I understand that I have been asked to participate in this study because I identify myself as biracial African American and Caucasian and I have participated in psychotherapy for a minimum of 5 sessions. I understand that participation requires that I am between the ages of 18 and 30, and that the therapy in question took place after the age of 18, and within the past 5 years. I also confirm that the psychotherapy took place in Southern California, and I currently reside in Southern California. I understand that if I do not meet these criteria, I cannot participate in this research project.
I agree to complete a 1 to 2 hour audio-taped, face-to-face interview in which I will be asked to describe various aspects of my therapy experience such as my therapist's characteristics, my experiences in therapy, and how biracial identity issues were dealt with in therapy. I understand that questions will focus on my therapist's characteristics such as age, gender, and race, my relationship with my therapist, how biracial issues were addressed in therapy, and the impact of race and ethnicity on the therapy. Additionally, I agree to provide demographic information including age, gender, level of education, and socio-economic status, and to disclose information regarding the reasons I was in therapy, and any diagnosis I was given. I understand that I may be contacted by phone or e-mail to answer follow-up questions or to clarify my earlier responses.
I understand that all information obtained in this study, including audio-tapes and transcribed data, will be kept confidential. All study-related materials will be stored in a locked file cabinet to which only the researcher will have access. The researcher will transcribe the interviews herself. The audiotapes and transcribed data will be kept for five years and then destroyed.
My participation in this study is voluntary. I understand that I may refuse to participate or withdraw from this study at any time without any penalty or loss of services to which I am entitled. I also have the right to refuse to answer any question I choose not to answer.
I understand that no information gathered from my participation in the study will be released to others without my written permission, or as required by law. Under California law, an exception to the privilege of confidentiality includes but is not limited to the alleged or probable abuse of a child, physical abuse of an elder or dependent adult, or if a person indicates that he or she wishes to do serious harm to self, others, or property. I am aware that the researcher is under obligation to seek consultation from the Human Subjects Review Committee on any ethical issues.
I understand that participating in this interview may bring up uncomfortable or painful memories and feelings for some people. I have been informed that if my participation in the study makes me feel uncomfortable, the researcher will be available to discuss my feelings with me. I have also been informed that, if necessary, I may contact Didi Hirsch Mental Health Center at (310) 390-6612 for further psychological assistance. Further, I acknowledge that a list of referrals has been provided to me for my reference.
I understand that, although I will not directly benefit from this research, my participation in this study will potentially add to a further understanding of the experiences and needs of biracial African American and Caucasian individuals in psychotherapy.
I understand that if the findings of the study are published or presented to a professional audience, no personally identifying information will be released. Separation of data from names of participants will be maintained throughout all stages of this project. Each participant will be identified only as Participant A, Participant B, etc. Transcribed data will be viewed only by the researcher and her supervisor.
I understand that I will receive $30.00 for participation in this study, upon completion of the tape-recorded interview. Additionally, I will be compensated $5.00 for transportation costs which I may incur while traveling to the interview location. I understand that there will be no further compensation for any brief follow-up discussions.
I understand that the researcher for this project is Sacha M. Dovick, M.A., a student at Pepperdine University in Culver City. The researcher will answer questions I have at any time about the project or about my participation in the project. I may contact her at ( ) - , or by e-mail at _________. If I have further questions or concerns, I may contact her supervisors, Dr. Shelly Harrell or Dr. Stephanie Woo, Chairman of the Human Subjects Review Committee, at Pepperdine University, 400 Corporate Pointe, Culver City, CA 90230, (310) 568-5600.
I have read this form and understand the statements contained therein. By signing below I agree to participate in the study and acknowledge that I have received a copy of this form.
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Name of Participant (please print)
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Participant's Signature Date
I, Sacha M. Dovick, M.A., have explained the procedures of this study to the above named participant and have answered all questions to the best of my ability.
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Sacha M. Dovick, M.A. Date
