Consent to be a Research Subject – Clients

Study Title:  Spiritually Integrative Couple Counseling
Principal Investigator:  Jennifer Ripley, Ph.D., Professor Regent University (Funding Sponsor Templeton/ BYU)
Telephone: 757-352-4296
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 for Lifecare Counseling and Coaching 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:

·     Each week when you come for couple counseling, you will complete online questionnaires on your smartphone, tablet, or a computer about how you are doing personally and in your relationship (5 minutes).

·     Your clinician will be able to see how you are doing, and you can talk about it with him or her at any time

·     The first session and after 6 sessions, you will be asked a few more questions about yourself and how things are going in counseling (about 8 minutes total).

·     From session 7 or more, you are welcome to continue the weekly questions if it is helpful to you and your clinician, but the research study only requests for the first 6 sessions.

·     Total time commitment will be 5 minutes per week, except the 1st and 6th session, which is about 8 minutes.

Risks/Discomforts: While not expected, it is possible that questions will remind of you of stress in your life.  Your counselor can help you if you feel distress, and we encourage you to talk with your counselor about the questionnaire.

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 you.

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 (fake name) so researchers won’t know who you are. There will be no identifying information from you, or your internet device, collected in the research. Your clinician will know who you are, but the researchers will not know who you are. 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 any given week. 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.

Your partner will not have access to your information unless you choose to discuss it or give your username/password to your partner.

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

Compensation: There is no compensation or cost to you for your involvement in the study.
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 clinician.  There is no penalty or loss of benefits to you. You will receive the same treatment from your clinician whether or not you decide to participate in this study.

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 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 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.

Question Title

* 1. Checking this box is equivalent to your signature of agreement to participate in this study.  You are free to decline participation with no consequence on the therapy you will be receiving.  You can withdraw at any time.

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* 2. Your name

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* 3. Name of your therapist

Thank you!

The link below will take you to the first part of the study with questions about your relationship and you personally.  

You will use the pseudonym of your street name from now on- not your real name.  Your name will not be associated with your data.