Consent Form for Chronic Illness Study

We are hoping to better understand the impact of chronic illness on mental well-being.  If you choose to participate in this study you will be asked to complete a survey with multiple questionnaires, including questions about your demographic information and your past medical history if applicable.  The demographic questions and additional questionnaires should not take longer than 30 minutes to complete.  You must be at least 18 years old to participate in the research study.     

Any information that you give us will be kept anonymous and be strictly confidential. Your name will not be connected with the information and instead you will be assigned a participant number. Participating in the study is up to you, and no one will hold it against you if you do not want to participate. If you do choose to participate in the study, you might experience mild discomfort talking about your mental and physical health. You can stop participating in the study at any point.

Should you choose to complete the questionnaire today, you will be given the option to be entered into a raffle to win one of two $50 gift cards to Target.

If you would like to know more about this study, please email Ann Taylor Adams at, or contact Dr. Marie LePage at 864-596-9130. If you have concerns about the ethics of this project, please contact Dr. Richard Keen at This project has been approved by the Converse College Institutional Review Board. 

Ann Taylor Adams
Principal Investigator

Dr. Marie LePage                             
Ph.D., Professor

* 1. Are you 18 years or older?

* 2. Do you consent to participate in this study?