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INFORMED CONSENT

Dear family of ___________________, your student has been randomly selected from the 7th grade to participate in the Esteem Team, a research study on increasing self-esteem amongst 7th grade girls. Though your student has been selected to participate, all participation is voluntary. Brandeis Zaklan, a School Counseling Masters student in Counselor Education program at Portland State University and the School Counseling intern at Hamlin Middle School, will be conducting the research study. The purpose of the Esteem Team self-esteem group for 7th grade girls, in support of Hamlins school culture and emphasizing the schools motto of P.R.I.D.E. (Personal responsibility: doing what is right, Respecting others: treat others the way you want to be treated, Integrity: be honest & trustworthy, Dedication: always do your best, Embracing Community: honor the qualities that make us unique), is designed to discuss and enhance existing qualities of participants in an effort to positively: 1. Promote self-esteem 2. Better handle peer-pressure 3. Plan for the future 4. Create a more solid positive self-image 5. Be leaders, mentors, and role models for younger girls 6. Develop leadership skills 7. Promote healthy ideas of fitness and body image Procedures and Activities The Esteem Team will meet for eight weekly sessions beginning Tuesday, January 28, 2013. The group will take place during the participants flex class time for 50 minutes and will meet in the conference room across from the counseling offices.

The group was created to help enhance traits students already possess in order to develop greater self-esteem. All participants will be asked to share personal thoughts, information, and feelings. At no time will anyone have to share anything they are not comfortable with. If there comes a time where a participant feels uncomfortable with any of the material discussed in the group, or they become upset during the course of the meetings and wish to speak to someone, they are encouraged to speak with Ms. Zaklan, Mrs. Mays, or Mr. Kennybrew which ever counselor they feel most comfortable talking to. Ground Rules All surveys completed by participants will be kept confidential in keeping with the professional and ethical guidelines provided by ASCA American School Counseling Association. It is important that both the participants and parents/guardians understand the limits of confidentiality. The feelings of safety and well-being of the participants is the first priority of the group, and ground rules will be established and agreed upon by the group in the first session. The foundation of the group shall be based on the principal that anything said in group is to be kept in confidence and not discussed outside of group. Further, the environment of each session will foster respect. However, it is important that all participants and parents/guardians of participants understand that that there are limits on confidentiality in regards to the potential need to consult with other professionals, privileged communication, and legal or authoritative restraints. As a school counselor, consulting with other professionally competent persons is essential in the school environment when it is in the students best interest to do so. As the parents/guardians, it is imperative that you are informed of the confidential nature of the counseling relationship between the counselor and student. Any information disclosed to Ms. Zaklan will be kept confidential unless disclosure is required to prevent clear and imminent danger to the student or others, or when legal requirements demand that confidential information be divulged.

Questions If you have any further questions please contact me, Brandeis Zaklan or my supervisor Jennifer Mays in the counseling office at (541) 744-6356. You may also contact Portland State Universitys Human Subjects Committee Chair person regarding your rights or those of your student as participant in a research study. The telephone number is (503) 725-4288. The office is located at Portland State University, Market Center Building, 6th floor, Portland, Oregon 97201. The office hours are from 9:00 a.m. to 5:00 p.m. Consent If you agree to allow your student to be a participant in Esteem Team, please fill out the attached permission and return it to the Counseling office. Thank you for your consideration, Brandeis Zaklan School Counseling Intern --------------------------------------------------------------------------------------------------------------------(see permission slip below)

Permission Slip Esteem Team self-esteem group research study

Parent/Guardian Consent By signing this consent form, I __________________________________ the parent/guardian of ______________________________________ acknowledge that I have read, and understand the intent of the Esteem Team group, the limitations on confidentiality, and give my permission for my child/guardians participation in the group to be held once a week for 8 weeks beginning January 28, 2013 during my daughters flex class time and overseen by counseling intern Brandeis Zaklan. Parent Signature_____________________________________ Date_______________________ Participant Consent By signing this consent form, I ________________________________________ willing agree to participate in the Esteem Team group with my parents signed consent above. I also agree that the expectations and limitations of the group have been explained to me in a way that I comprehend by Ms. Zaklan. I have also been made fully aware that at any time I can change my mind and do not have to take part in the Esteem Team group and that participation is voluntary. Participant Signature__________________________________ Date______________________