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Consent Form
You have been invited to take part in a research study which seeks to evaluate the perceived acceptability and effectiveness of a cognitive-behavioral counseling program and identify factors that influence school administrators and school psychologist’s perceptions of the program. This study is being conducted by Stephanie Schwartz, a doctoral candidate at St. John’s University, under the supervision of Dr. Mark Terjesen, Director of the School Psychology Program at St. John’s University.
If you agree to be in this study, you will be asked to do the following:

     1. Complete a questionnaire about your background (age, gender, education, etc.)
     2. Read a brief description of a counseling program and answer related questions.
Participation in this study will involve approximately 10-15 minutes of your time. There are no known risks associated with your participation in this research beyond those of everyday life. Although you will receive no direct benefits, this research may help the investigator understand the perceived acceptability and effectiveness of a new counseling program and factors that influence these perceptions.
Participation in this study is anonymous, and thus identifying information (name, phone number, address, etc.) will not be asked of you as part of this study. Thus, your identity will not be known or linked with any information you have provided. Only the principal investigator and the faculty supervisor will have access to the data. It will be stored in an electronic file and will be destroyed after a period of 5 years.
Participation in this study is voluntary. You may refuse to participate or withdraw at any time without penalty. You have the right to skip or not answer any questions you prefer not to answer.
If there is anything about the study or your participation that is unclear or that you do not understand, if you have questions or wish to report a research-related problem, you may contact Stephanie Schwartz, at or the faculty sponsor, Mark Terjesen, at
For questions about your rights as a research participant, you may contact the University’s Institutional Review Board, St. John’s University, Dr. Raymond DiGiuseppe, Chair 718-990-1955 or Dr. Marie Nitopi, IRB Coordinator, 718-990-1440.

Statement of Consent:

I have read the above information.  I have asked any questions I had regarding this study and they have been answered to my satisfaction, or I did not have any questions.  By indicating "yes" below, I consent to participate in the present study.

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