Consent Form

Consent Form

Hannah Barbash, M.A.

University of Hartford

Graduate Institute of Professional Psychology

200 Bloomfield Ave., East Hall-117H,
West Hartford, CT  06117.

Dear Participant,


You are being asked to participate in a research study.  However, before you consent to be a volunteer, we want you to read the following and ask as many questions as necessary to be sure you understand what your participation will involve.

The purpose of this study is to gain a better understanding of how psychotherapy can be helpful to women after finding out their positive BRCA 1 and/or 2 status.  If you agree to participate, you will be asked to fill out one questionnaire, with various questions about yourself and one 17 question scale with questions focused on your specific experience of being BRCA positive.  Overall, it should take approximately 30 minutes to complete both forms.   For some women, filling out these questionnaires may be upsetting.  If the questionnaires prove to be too upsetting, you can opt to no longer participate in this study. Additionally, there is a peer support toll-free hotline 1-866-288-RISK (7475) to discuss issues relevant to genetic predispositions to cancer.  Both questionnaire and scale can be sent to you by email or snail mail and in turn, can be sent back to us, either by email or snail mail. 

You have a right to privacy and all identifying information will remain anonymous and confidential.  Your answers on all questionnaires will coded with numbers and only the primary researcher will have access to names, and due to APA guidelines, the data will be kept securely for five years subsequent to the study. The results of this study may be published in scientific journals or be presented at psychological meetings as long as you are not identified and cannot be reasonably identified from it.

Your participation in this study is voluntary.  You may refuse to participate or withdraw once the study has started. There will be no monetary benefits, however participants will be able to access the results of the study from the P.I. after completion.   If you have any questions or concerns, you may contact Hannah Barbash at (914) 420-4482 or  You may also contact Dr. John Mehm at (860) 768-5224 or at University of Hartford, 200 Bloomfield Ave., East Hall-117H, West Hartford, CT  06117. 

If you have any questions about your rights as a research subject, please contact the University of Hartford Human Subjects Committee (HSC) at 860.768.4721. The HSC is a group of people that reviews research studies and protects the rights of people involved in research.

My signature below indicates that I have read the above information and have had a chance to ask questions to help me understand what my participation will involve.  I agree to participate in the study until I decide otherwise.  I acknowledge having received a copy of this agreement.  I have also been told that by signing this consent form I am not giving up any of my legal rights.

____________________________                                                 ________

Question Title

* 1. Do you agree?