Consent Form

Survey conducted by: Family Crisis Services/Outreach

Survey purpose: This survey is meant to examine the effectiveness of the Outreach Office services.

Procedure and duration of survey: This survey should take up to 5 minutes to complete. We will be administering the option of confidential paper survey or an electronic survey that will be issued through Survey Monkey. Both surveys, either paper or electronic, will have the same questions. If you choose the paper format to participate in this study, the Outreach Office will mail you a copy of the survey with self addressed pre-stamped return envelope.

Voluntary nature: Your participation in this study is both voluntary and confidential. At any time, you may choose not to participate or have your responses counted. You may choose not to respond to particular questions. You may choose to withdraw your participation in the study at any time without consequence.

Confidentiality: Your responses will not impact your standing as a client with Family Crisis Services. The results of this study will only be viewed and analyzed by Family Crisis Services.

Risks and benefits: The electronic format of this study will be distributed through Survey Monkey. The Survey Monkey website uses their own systems to maintain a secure format of confidentiality. The paper format of this study will be distributed through the mail. If you choose to participate using the mailed survey, there are general risks associated with sending mail through the U.S. postal service. All responses, once received, will be confidential.

Contact information: If you have questions or concerns, you may contact the Family Crisis Services Outreach Office at (207) 874-8512, 109 Middle St. Portland, ME 04101.

Implied consent: By agreeing to this consent form, it is implied that you are at least 18 years old, have read this form, and that you are agreeing to participate in this study.

* 1. Do you agree to this consent form?