Youth - Other

Youth—Other

Attachment B: System of Care Assessment

Youth Stipend Receipt 
Date:

__________________________________

Project:

CMHS, #633430.0.008.0x.005

Location:

__________________________________

I, _____________________________________, received $15.00 for my participation in an
(Print Name)

interview for the national evaluation of the Comprehensive Community Mental Health
Services for Children and Their Families Program.

_____________________________________
(signature)

System/Program__________________________

Interviewer___________________

Interviewed______________________________

Assessment #_________________

Informed Consent
System of Care Assessment
Youth (18–21 years old)
Purpose
The (name of grant program) in your community provides services to children and youth and their families. The Center
for Mental Health Services in the Federal government wants to know more about these services. They want to know
how well these services work. The National Evaluation Team is talking to youth and their families in (name of grant
program) to learn more about how to make these services better. I would like to ask you some questions about (name of
grant program). You will be able to tell me what you think about the program and the services you have received.
This interview will last about 45 minutes. To help you decide if you want to participate in this interview, here are some
things to know:
•

Your participation is voluntary and completely by your own choice.

•

You may choose to stop the interview at any time and for any reason. You also may choose not to answer any of
the questions.

•

The information you provide to us will be carefully protected. Your name will not be used in any reports from this
interview.

•

You will receive $15 in appreciation for meeting with me today.

•

We have obtained a Certificate of Confidentiality (CC) from the U.S. Department of Health and Human Services
(DHHS) to keep anything that you tell us private. This means that we will not tell anyone what you tell us even if a
judge tries to force us to identify you as a person in the study. You should know, however, that we may tell local
authorities if harm to you, harm to others, or if child abuse/neglect becomes a concern. Also, the government
agency that has provided the money for this project may see your information if they ask for our records to ensure
we were conducting the project correctly. The CC that we have does not mean that DHHS approves or disapproves
this project.

•

You will not get any benefit from participating in the interview. A risk is that you may feel uncomfortable about
answering questions about your experiences in (name of grant program).

•

I will answer any questions you have about this interview before we begin. If you have questions after the interview
is over, you may contact Mary Spooner at ICF, Atlanta, GA. Her toll-free telephone number is 1-866-368-5657.

Voluntary Consent
I read this form or it has been read to me. I understand what it says. My questions (if any) have been answered. A copy
of this form will be given to me. By signing my name below, I freely agree to participate in this interview.
Participant Printed Name _________________________________________________________
Participant Signature __________________________________________________________________
Witness__________________________________________________________Date________________

CMHI National Evaluation

2 signed forms: 1 for the interview participant and 1 for the interviewer

System/Program__________________________

Interviewer___________________

Interviewed______________________________

Assessment #_________________

Informed Assent
System of Care Assessment
Youth (14–17 years old)
The (name of grant program) in your community provides services to children and youth and their families. The
Center for Mental Health Services in the federal government wants to know more about these services. They want
to know how well these services work. The National Evaluation Team is talking to children and youth and their
families in (name of grant program) to learn more about how to make these services better. I would like to ask
you some questions about (name of grant program). You will be able to tell me what you think about the program
and the services you have received.
This interview will last about 45 minutes. To help you decide if you want to participate in this interview, here are
some things to know:
•

Your participation is voluntary and completely by your own choice.

•

You may choose to invite your parent or caregiver to sit in on the interview.

•

You may choose to stop the interview at any time and for any reason. You also may choose not to answer any
of the questions.

•

The information you provide to us will be carefully protected. Your name will not be used in any reports from
this interview.

•

You will receive $15 in appreciation for meeting with me today.

• We have obtained a Certificate of Confidentiality (CC) from the U.S. Department of Health and Human
Services (DHHS) to keep anything that you tell us private. This means that we will not tell anyone what you
tell us even if a judge tries to force us to identify you as a person in the study. You should know, however, that
we may tell local authorities if harm to you, harm to others, or if child abuse/neglect becomes a concern. Also,
the government agency that has provided the money for this project may see your information if they ask for
our records to ensure we were conducting the project correctly. The CC that we have does not mean that
DHHS approves or disapproves this project.
•

You will not get any benefit from participating in the interview. A risk is that you may feel uncomfortable
about answering questions about your experiences in (name of grant program).

•

I will answer any questions you have about this interview before we begin. If you have questions after the
interview is over, you may contact Mary Spooner at ICF, Atlanta, GA. Her toll-free telephone number is 1866-368-5657.

Voluntary Assent
I read this form or it has been read to me. I understand what it says. My questions (if any) have been answered. A
copy of this form will be given to me. By signing my name below, I freely agree to participate in this interview.
Participant Printed Name ______________________________________________________________
Participant Signature __________________________________________________________________
Witness________________________________________________________ Date__________________

CMHI National Evaluation

2 signed forms: 1 for the interview participant and 1 for the interviewer

Attachment F: Consent Letters for Longitudinal Child and Family Outcome Study
and Service Experience Study

SAMPLE INFORMED ASSENT—YOUTH VERSION
(Suggested Content and Wording)

Key Components of a Consent Form
Elements to Include:
Purpose of the Study
• Funding source
• Local system of care name
• Description of why the study will
be conducted

Description of Participation
• Participant responsibilities
• Description of data collection
methods: interviews--frequency,
duration; record review;
observation, etc.
• Other guidelines (e.g., possible
data sources, age, changes in
participation over time, etc.)

Risks and Benefits
• Potential risk factors associated
with participation
• Potential benefits that may be
gained through participation

Purpose
The (system of care name) in your community provides services
to children and families. The Center for Mental Health Services in
the Federal government wants to know more about these services.
They want to know how well these services work. The National
Evaluation Team is talking to children and families in the (system
of care name) to learn more about how to make these services
better.
The person who takes care of you has been asked questions for
this project in the past. Because you are now 11 years old, we
would like to ask you questions. You will be able to tell us about
yourself and what you think about the services you have received.

Description of Participation
You will have an interview every 6 months. You may have up to five
interviews. You may have fewer interviews, depending upon when
you started services. We can talk with you in your home or any
other place that is best for you. Each interview will take about 1
hour.
You will be asked questions about how you feel. You will be asked
about what you do at home, in school, and in your neighborhood.
You will be asked about what you do with your family and friends.
You will be asked about the services you have had. We will still ask
to talk to you if you stop getting services.

Compensation for Participation
• Type and amount of
compensation participant will
receive for participation

Contact Information
• Contact information for
someone working on the study
who will be available to answer
participant questions

We would like you to let us look at your school records. These
records include your grades, how much you were absent, and if you
were ever in detention. We want to look at court records and
records about your services. We may also want to talk to people
who work for the court or your school.

Risks and Benefits
You will not get any benefits from being in this project. A risk is that
you may feel uncomfortable about answering questions about
yourself.

Compensation
You will receive $XX for each interview to thank you for your time.

Contact Information
If you have any questions about this evaluation project, you can call
(evaluator) to have your questions answered. You can call him/her
collect at (555) 555-5555. To contact the Institutional Review Board
that reviewed this project, call (555) 555-5555.

Continued on next page

Sample Informed Assent—Youth Version

| Page 1 of 2 | April 2011

Key Components of a Consent Form
Protection of Information
• Protocol for maintaining participant
privacy
• Mandated reporting requirements
• Description and purpose of the
Federal Certificate of Confidentiality
Rights Regarding Decision to Participate
• Statement of participant rights to
terminate participation at will
• Statement that the termination of
participation will not lead to adverse
consequences
Voluntary Assent
• Statement of participant
understanding of the assent form
• Statement that participant has had all
of his or her questions answered
• Permission to be interviewed
• Permission to access service provider
records for 12 months previous to
service and 24 months after the first
service
• Signature line for participant to sign,
thus assenting to participate
• Signature line for guardian signature
• Date

Protection of Information
Anything we learn about you will be kept as secret as possible.
We have taken steps to protect your privacy. None of the
information for this study will have your name on it. It will have
only special codes. Papers with your name on them will be
kept in a locked filing cabinet. In reports, your information will
be grouped together with information from others. We will
never mention your name. Only approved people will be able to
see your information. The information will be shared with the
agency that pays for this study, companies that work for them,
and other places that provide services to you.
There are some times when we cannot promise to keep your
name secret. If you tell the person who interviews you that you
plan to hurt yourself or someone else, then she/he will have to
tell a doctor or some other authority so that you can get help.
Interviewers must obey State laws and report certain kinds of
diseases that other people can catch. And they must report
child abuse.

Also, we have applied for a Certificate of Confidentiality from
the Federal government to protect the people who interview
you from being forced, even under a court order or subpoena,
to identify you. An exception to privacy is if we learn about child
abuse or neglect or if you tell the person who interviews you
that you plan to harm yourself or someone else, then he/she
will tell a doctor or some other authority so that you can get
help. Interviewers may report child abuse. In addition, the
Federal agency funding this research may see your information if it audits us. The Certificate of
Confidentiality does not imply that the government has approved or disapproved of this project.

Rights Regarding Decision to Participate
I understand that I will not be in trouble if I do not want to be in the study or if I decide to quit later. I do not
have to answer questions that I do not want to answer. If I change my mind and quit, all of my answers to
questions will be destroyed, if that is what I want. No one will say that I can’t be in other projects because
I don’t want to be in this project. No one can say that I cannot get services because I don’t want to be in
this project.

Voluntary Assent
I read this form, or it has been read to me, and I understand what it says. My questions (if any) have been
answered. A copy of this form will be given to me. By signing my name below, I freely agree:
ƒ to be interviewed every 6 months, for up to 24 months

____

ƒ to have the project access my mental health records,
Past 12 Months Next 24 Months
education records, juvenile justice records, department of
social services and child protection records, or service records
____
____
from other services coordinated through (system of care name)
Youth’s Name (Type or Print Full Name): ______________________________________
Signature of Youth: ________________________________________

Date: ___/___/____

I, _____________________________________, have read the above. My child may participate.
(Caregiver/Guardian)
Guardian’s Signature: ______________________________________
Sample Informed Assent—Youth Version

Date: ___/___/____

| Page 2 of 2 | April 2011

INFORMED CONSENT—YOUNG ADULT VERSION
(Suggested Content and Wording)

Components of a Consent Form
Elements to include:
Purpose of the Study
• Funding source
• Local program name
• Description of why the study will
be conducted

Description of Participation
• Participant responsibilities
• Description of data collection
methods: interviews--frequency,
duration; record review;
observation, etc.
• Other guidelines (e.g., possible
data sources, age, changes in
participation over time, etc.)

Risks and Benefits
• Potential risk factors associated
with participation
• Potential benefits that may be
gained through participation

Compensation for Participation
• Type and amount of
compensation participant will
receive for participation

Contact Information
• Contact information for
someone working on the study
who will be available to answer
participant questions

Purpose
The Center for Mental Health Services in the United States Department
of Health and Human Services is sponsoring a national evaluation of
programs that are funded to improve community-based mental health
services for children and families. You were invited to participate in this
project because you received such services. At that time, your family
agreed to participate in the project we are doing. Now that you are 18
and a legal adult, we need to ask you again if you would like to
continue participation in the project. In this project, we are interested in
finding out about how you feel; what you do at home, in school, and in
the neighborhood; the kinds of services you have received; and how
you feel about these services. The results of the project will be used to
help improve the quality of services for children and families. The
national evaluation is authorized by Section 565 of the Public Health
Service Act.

Description of Participation
We will interview you up to five times depending upon whether you
entered the study at the beginning or toward the end. Participation
includes follow-up interviews every 6 months while you are in the
evaluation. We will ask you to continue to participate in the project
even if you do not receive services any longer. The interviews will be
conducted in your home or any other place that is convenient for you.
Each visit will take about 1 hour.
You will be asked questions about your behavior at home, in school,
and in the community. We will also ask you questions about your family
and your experiences with the services you have received, including
mental health and substance use services.
As part of the project, we would like your permission to make use of
your school records, including disciplinary, attendance, and transfers,
and other records related to services you may have received (for
example, juvenile court records, records from the department of human
services and child protection, mental health services records). Your
agreement to participate in this project and your signature on this form
provide your permission for the release of any of these records. We
may also want to ask questions of agency representatives from
juvenile court, the department of human services and child protection,
and/or your school.

Risks and Benefits
You will not get any benefits from being in this project. A risk is that you
may feel uncomfortable about answering questions about yourself.

Compensation
You will receive $XX for each interview to thank you for your time.

Contact Information
If you have any questions about this evaluation project, you can call
(evaluator) to have your questions answered. You can call him/her
collect at (555) 555-5555. To contact the Institutional Review Board
that reviewed this project, call (555) 555-5555.

Continued on next page
Informed Consent—Young Adult Version

| Page 1 of 2 | April 2011

Components of a Consent Form
Protection of Information
• Protocol for maintaining participant
privacy
• Mandated reporting requirements
• Description and purpose of the
Federal Certificate of Confidentiality

Rights Regarding Decision to Participate
• Statement of participant rights to
terminate participation at will
• Statement that the termination of
participation will not lead to adverse
consequences

Voluntary Consent
• Statement of participant
understanding of the consent form
• Statement that participant has had all
of his or her questions answered
• Permission to be interviewed
• Permission to access service provider
records for 12 months previous to
service and 24 months after the first
service
• Signature line for participant to sign,
thus assenting to participate
• Signature line for guardian signature
• Date

Protection of Information
Anything we learn about you will be kept as secret as
possible. We have taken steps to protect your privacy. None of
the information for this study will have your name on it. It will
have only special codes. Papers with your name on them will
be kept in a locked filing cabinet. In reports, your information
will be grouped together with information from others. We will
never mention your name. Only approved people will be able
to see your information. The information will be shared with
the agency that pays for this study, companies that work for
them, and other places that provide services to you.
There are some times when we cannot promise to keep your
name secret. If you tell the person who interviews you that you
plan to hurt yourself or someone else, then she/he will have to
tell a doctor or some other authority so that you can get help.
Interviewers must obey State laws and report certain kinds of
diseases that other people can catch. And they must report
child abuse.
Also, we have applied for a Certificate of Confidentiality from
the Federal government to protect the people who interview
you from being forced, even under a court order or subpoena,
to identify you. An exception to privacy is if we learn about
child abuse or neglect or if you tell the person who interviews
you that you plan to harm yourself or someone else, then
he/she will tell a doctor or some other authority so that you can
get help. Interviewers may report child abuse. In addition, the
Federal agency funding this research may see your
information if it audits us. The Certificate of Confidentiality
does not imply that the government has approved or
disapproved of this project.

Rights Regarding Decision to Participate
I understand that I will not be in trouble if I do not want to be in the study or if I decide to quit later. I do not
have to answer questions that I do not want to answer. If I change my mind and quit, all of my answers to
questions will be destroyed, if that is what I want. No one will say that I can’t be in other projects because
I don’t want to be in this project. No one can say that I cannot get services because I don’t want to be in
this project.

Voluntary Consent
I read this form or it has been read to me. I understand what it says. My questions (if any) have been
answered. A copy of this form will be given to me. By signing my name below, I freely agree:
ƒ to be interviewed every 6 months, for up to 24 months

____

ƒ to have the project access my mental health records,
Past 12 Months Next 24 Months
education records, juvenile justice records, department of
social services and child protection records, or service records
____
____
from other services coordinated through (system of care name)
Young Adult’s Name (Type or Print Full Name): ______________________________________
Signature of Young Adult:
________________________________________
Date: ___/___/____
Informed Consent—Young Adult Version

| Page 2 of 2 | April 2011