EMU Psychology Clinic
Consent for Research Participation and Future Contact
The Psychology Clinic is a training clinic for service and research. Clinic data are used for a variety of clinical purposes, for
example, to aid in assessing your progress during treatment, to help train or evaluate student clinicians, and to track
service utilization. Data may also be used for archival research purposes. That is, we may use data gathered from closed
cases to answer clinical research questions. Access to and use of this data for research purposes will be limited to
Psychology faculty and graduate students who have received prior research approval from the EMU Human Subjects
Research Review Committee.
[
] 1. Your signature on this form gives us permission to use your data. Your permission is entirely voluntary and you
will not be penalized in any way should you choose to withhold your consent.
[
] 2. I understand that data about my case and progress will be coded into a database and may be used in archival
research. I understand that data from my case will be coded into research databases without any identifying
information attached, protecting my anonymity and the confidentiality of my data.
 I consent to use of my data for research
 I do not consent to use of my data for research
Client or Guardian, Full Name
Client or Guardian, Signature
Date
Clinician, Signature
Date
Sometimes, we conduct psychological research studies in which clinic clients are asked to participate. If you are ever to
be involved in a research study, you would be asked to provide written informed consent that you agree to participate
before you provide data. However, occasionally, the design of a research project is such that the investigator needs to
contact research participants in the future, after they have ended their active involvement as a clinic client, to verify
existing data or collect additional data. Or, sometimes we may want to follow-up with clients about the outcome of their
treatment or assessment, for purposes of psychological research investigation.
[
] 3. Your signature below gives a research investigator permission to make such contact with you. If you are willing
for the possibility of such contact, please give us an address where we will have the most success in locating
you. Any contact attempted will be done in a manner that protects your confidentiality (i.e., unmarked envelopes
and callers who do not identify themselves as calling from the Psychology Clinic until they are talking directly to
you). Your permission is entirely voluntary, and you will not be penalized in any way should you choose to
withhold your consent. The treatment you receive at the Psychology Clinic will not be affected by your decision.
 I consent to being contacted about future research studies
 I do not consent to being contacted about future research studies
Client or Guardian, Signature
Client Address
Date
Clinician, Signature
Date
Client City, State, ZIP Code
 Yes  No
Client Phone Number
Special Calling Instructions?
OK to leave msg?
Consent for Research (Rev. 6/15)