“People Who Self-Injure”

Principal Investigator, Patti Adler

PARENTAL PERMISSION FORM

Revised May 2005

I am willing to take part in the study called “People who Self-Injure.”  I understand that Patti Adler, the researcher from the University of Colorado , is hoping to learn about the people who do this, why they do this, and how it affects them.  I understand that I will participate in an interview with Dr. Patti Adler in her office or on the telephone and that she will tape record this to ensure accuracy of her recall.  I will be asked about when I first heard about self-injury, what I thought of others who did it, how I came to do it myself, how it felt, and how I came to stop (if applicable).  This study will take place either on the telephone or in Dr. Patti Adler’s office at the University of Colorado and should take anywhere from 45 minutes to two hours of my time.  I know that I can stop the interview at any time.  If I do not like a question, I do not have to answer it, and if I ask, my answers will not be used in the study.  No one will know my answers, including my parents, my siblings, or anyone else I do not want to know. This will be a private conversation between Patti Adler and me.

 Name___________________________________________________________ 

Signature _______________________________________________________

 Date____________________________________________________________

 Age____________________________________________________________ 

  return to research page