Sponsor / Study Title: “Spiritually integrative couple counseling”   Lifecare Counseling and Coaching/ BYU
Principal Investigator:  Jennifer Ripley, Ph.D.
Telephone:  757-352-4296 (24 Hours)
Address:  Lifecare Counseling and Coaching
1601 Jones Franklin Road, Suite 104
Raleigh, NC  27606

Please read this form carefully.  Take time to ask the investigator or study staff as many questions about the study as you would like.  The investigator or study staff can explain words or information that you do not understand.  Reading this form and talking to the investigator or study staff may help you decide whether to take part or not. 

Introduction
This research study is being conducted by Jennifer Ripley PhD contracted for Lifecare to determine the nature and outcome of spiritually integrated couple therapy. You were invited to participate because you have asked to begin couple therapy in a clinic that provides spiritually integrated couple therapy.

Procedures

If you agree to participate in this research study, the following will occur:

·         When you sign up for the study we will ask questions about your demographics, typical approach to therapy, personal religion, and feelings about being a therapist. (about 20 minutes)

·         Each week when your couples come to counseling you will complete an online questionnaire on your smartphone, tablet, or a computer, about what happened in couple therapy (5 minutes)

·         After 7 or more sessions, you are welcome to continue the weekly questions if it is helpful to you and your client but there is only compensation for the first 6 sessions.

·         When a case reaches 6 sessions, or terminates, we will ask you to complete a brief questionnaire about what happened with the case overall.  (5 minutes)

·         At the end of the study we will ask a few questions about your feelings about being a therapist (5 minutes)

·         Total time commitment will be 5 minutes per case each week, 20 minutes initial questionnaire, 5 minutes at the close of a case, and 5 minutes at the close of the study.

Risks/Discomforts
While not expected, it is possible that questions will cause distress if clients responses are unexpected or distressed. 

Benefits
Many clients and their clinicians find it helpful to track how they are doing each week through the time they are in counseling.  You might find this helpful for your work as a clinician.

Your participation in this research may help researchers better understand the process of therapy, and how spirituality affects couple counseling.

This study is for research purposes only. The only alternative is to not participate in this study.

Confidentiality

You will use a pseudonym.  There will be no identifying information from you, or your internet device, collected online.  Dr. Ripley and her colleagues will keep a record of clinician names, but this will be password protected and kept separate from all your responses just to be able to match up the weekly questions online with other questions at the beginning of the study.  The online system will not have your name.  All published data will be in aggregate (group) form, not individual information.

The data will be stored in a secure password protected online system that is maintained by research staff.  That data will not be shared outside of the necessary researchers. 

There may be a “back up” paper copy of the questionnaire in case of technology problems.  If you end up using the paper questionnaire it will only have your pseudonym on it and will be confidentially faxed scanned or mailed to the researchers.

The sponsor, the sponsor’s representatives, the Department of Health and Human Services, and Chesapeake IRB may have access to the study data.
Compensation

For each week that you complete the questionnaires for each couple case and submit it online, you will receive $5.00.  A maximum of $30 per couple would be received. The researchers will need a simple log of your participation scanned, faxed or mailed to them in order to be able to process funds.  Compensation will be regularly done, at least quarterly. There is no cost to you.

Participation

Participation in this research study is voluntary. You have the right to withdraw at any time or refuse to participate entirely without jeopardy to your standing with your employer or any agency involved in this study.  There is no penalty or loss of benefits to you.

You may be asked to leave the study without your consent for administrative reasons. If you want to stop taking part in the study, contact the investigator or the study staff at the telephone number listed on the first page of this form.

You will be told about any new information found during the study that may affect whether you want to continue to take part. 

Questions about the Research
If you have questions regarding this study, you may contact Dr. Ripley at 757-352-4296 or jennrip@regent.edu for further information.

This form has been reviewed by an Institutional Review Board (IRB). Chesapeake IRB reviewed this study to help ensure that your rights and welfare are protected and that this screening is carried out in an ethical manner. If you would like to contact them about your rights as a research subject, their email address is adviser@chesapeakeirb.com and the toll free number is 877-992-4724. The study number is Pro00024233.

Statement of Consent
I have read, understood, and received a signed and dated copy of the above consent and desire of my own free will to participate in this study.

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* 1. I consent to participate in this study.  Clicking the box below is equivalent to signing a consent form

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* 2. Your name

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* 3. What practice are you affiliated with?

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* 4. How did you hear about Project Bridges

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* 5. Your email (our staff will typically contact you by email with any questions so please give your best email.  We will never share your email address).

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* 6. Phone number to reach you (if we have questions about data or your payments, a number to reach you)

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* 7. Can you receive text at this phone?

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* 8. Alternate emails or phone numbers to reach you.

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* 9. An address (to send checks to for the $5/session honorariums)

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* 10. We like to offer a brief 15-20 minute training in the procedures for the study to ensure that the data comes in properly and ethically.  How would you prefer to do this training? 

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* 11. I can always manage to solve difficult problems (in Spiritually Integrated Couple Counseling; SICC) if I try hard enough.

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* 12. If someone opposes me, I can find the means and ways to get what is needed in SICC.

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* 13. I am certain that I can accomplish my goals for SICC.

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* 14. I am confident that I can deal efficiently with unexpected events in SICC.

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* 15. Thanks to my resourcefulness, I can handle unforeseen situations in SICC.

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* 16. I can solve most problems in SICC if I invest the necessary effort.

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* 17. I can remain calm when facing difficulties in SICC because I can rely on my coping abilities.

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* 18. When I am confronted with a problem in SICC, I can find several solutions.

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* 19. If I am in trouble, I can think of a good solution for SICC.

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* 20. I can handle whatever comes my way in SICC.

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* 21. Read each item carefully. Using the scale shown below, please select the number that best describes how you think about your couples counseling practice right now and put that number in the blank before each sentence. Please take a few moments to focus on your couple counseling practice at this moment. Once you have this “here and now” mindset, go ahead and answer each item according to the following scale:

  1- definitely false 2- mostly false 3- somewhat false 4- slightly false 5- slightly true 6- somewhat true 7- mostly true 8- definitely true
If I should find myself in a jam (with Spiritually Integrated Couple Counseling), I could think of many ways to get out of it.
At the present time, I am energetically pursuing my goals for spiritual couple counseling.
There are lots of ways around any problem that I am facing now with couples.
Right now, I see myself as being pretty successful at spiritual couple counseling.
I can think of many ways to reach my current goals for spiritual couple counseling.
At this time, I am meeting the goals that I have set for spiritual couple counseling.

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* 22. What is your profession?

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* 23. What is your professional degree (in your profession)

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* 24. What is your license to practice?

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* 25. What year did you begin practicing as a therapist/ counselor?

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* 26. Your Date of Birth

Date / Time

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* 27. Your gender

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* 28. Please describe your race/ethnicity.

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* 29. Your marital status

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* 30. How many hours a week do you typically see clients?

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* 31. What is your religious identity/ affiliation?

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* 32. Personal Religious

  Not at all true of me Somewhat true of me Moderately true of me Mostly true of me Totally true of me
I often read books and magazines about my faith.
I make financial contributions to my religious organization.
I spend time trying to grow in understanding of my faith.
Religion is especially important to me because it answers any questions about the meaning of life.
My religious beliefs lie behind my whole approach to life.
I enjoy spending time with others of my religious affiliation.
Religious beliefs influence all my dealings in life.
It is important to me to spend periods of time in private religious thought and reflection.
I enjoy working in the activities of my religious affiliation
I keep well informed about my local religious group and have some influence in its decisions.

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* 33. How often do you pray privately in places other than at church or synagogue?

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* 34. How often do you read, watch or listen to religious programs on the internet/ TV or radio?

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* 35. How often do you read the Bible or other religious literature?

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* 36. How often are prayers or grace said before or after meals in your home?

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* 37. In general when you see couples for couples counseling with couples, what approaches to therapy do you use?  Check ALL that you generally use.

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* 38. If you have a couple who you are doing spiritually-integrated counseling with.  Which of the following would you possibly use?  Check all that you would use.

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* 39. Any comments for the researchers?  If you want to talk with us please feel free to call Dr Ripley at 757-352-4296 or email us at bridgecouplesresearch@gmail.com

When you click "Done" below you will be taken to another questionnaire- which will take about 5-10 minutes.  This study is part of a larger research study around the world.  This current survey you just finished is for Dr. Ripley's study in couple therapy only.  When you go to this link you will be asked questions that are shared with the central research team for the Bridges study which has 20 studies around the world and hundreds of therapists.  Your information is very important for this research.

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