�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____________________________________________________________ 

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