Consent Form

Investigators: Annum S. Rentiya
Study Title: Barriers to Mental Health Treatment in the United States Muslim Community

I am a student at The Chicago School of Professional Psychology. This study is being conducted as part of my dissertation requirements for the Clinical Psychology Psy.D. program.

I am asking you to participate in a research study about the potential barriers to mental health treatment in the Muslim community. You will be asked to complete a survey that will take approximately 15 minutes. Answering certain questions about mental health and religion may feel uncomfortable or cause distress. You may, however, choose whether or not to answer the question. You may also exit out of the survey at any time. In the event that you experience severe discomfort or distress please talk to someone or contact a mental health hotline (e.g., NAMI helpline [1-800-950-NAMI (6264)], SAMHSA national helpline [1-800-662-HELP (4357)]). Additionally, if you choose to participate in the raffle by providing your email at the end of the survey, your confidentiality in the study is not guaranteed. Although you may not directly benefit from this study, it will help to understand the challenges the Muslim community experiences when experiencing poor mental health and needing treatment. Furthermore, this study will help providers create and provide culturally sensitive treatments and educational programs to better assist the Muslim community.

Please take your time to read the entire document and feel free to ask any questions before continuing with the survey.
Purpose: The purpose of this study is to examine the barriers to seeking and receiving appropriate mental health treatment in the Muslim community and how those barriers compare between different demographic groups within the community.

Procedures: This study will ask you to complete an online questionnaire. The survey will ask you to provide demographic information and your opinions regarding certain topics, such as mental health, stigma, cultural sensitivity, psychological treatments, and financial elements. Please respond honestly to the questions. You may choose whether or not to answer a question. You may also exit out of the survey at any time. The survey will take approximately 15 minutes to complete. You are allowed assistance in completing the survey. You may wish to provide your email at the end of the survey to participate in the raffle.

Compensation: Participants who wish to enter in the raffle will enter their emails at the end of the survey. At the end of the data collection period, ten randomly selected participants will win a $20.00 Visa gift card.

Risks to Participants: The risks associated to participating in this study is that answering some questions may cause discomfort or distress. In this event, you may choose whether or not to answer the question. You may also exit out of the survey at any time. In the event that you experience severe discomfort or distress please talk to someone or contact a mental health hotline (e.g., NAMI helpline [1-800-950-NAMI (6264)], SAMHSA national helpline [1-800-662-HELP (4357)]). Additionally, if you choose to participate in the raffle by providing your email, your confidentiality is not guaranteed. Entering in the raffle, however, is optional. If you do choose to enter the raffle, your email address will be stored in a password-protected document, separately from other data collected.

Benefits to Participants: There are no direct benefits from this study. However, we hope that the information obtained from this study will benefit the Muslim community’s ongoing discussions about mental health and contribute to the literature on mental health in the Muslim population.

Alternatives to Participation: Completing this survey is voluntary. You may withdraw from study participation at any time without any repercussions.

Confidentiality: During this study, the following personal identifying information will be collected – age, the state you currently reside in, your citizenship status, highest education level, current employment status, race, ethnicity, gender, current marital status, and email address. Providing this information is your choice. You are under no obligation to do so. To maintain anonymity, Survey Monkey will be set to “anonymous responses.” Additionally, IP addresses will not be collected. Furthermore, all raw data will be password protected. The results of the study will be reported as a collective summary with no identifying information present. All data will be kept for a minimum of five years after publication per the American Psychological Associations’ (APA) guidelines. After that time, the data will be securely deleted off of the computer’s hard drive.

It is possible that your data may be used for future research or distributed to another researcher without your consent. However, there is no information collected that could identify you.

Your research records may be reviewed by federal agencies whose responsibility is to protect human subjects participating in research, including the Office of Human Research Protection (OHRP) and by representatives from The Chicago School of Professional Psychology Institutional Review Board, a committee that oversees research.

Questions/Concerns: If you have any questions related to the procedures described in this docume

Question Title

* 1. I have read the above information. I understand the research project and the procedures involved have been explained to me. I agree to participate in this study. My participation is voluntary, and I do not have to continue to the survey if I do not want to be part of this research project.

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