LETTER OF CONSENT TO PARTICIPATE IN RESEARCH:

Can Ketamine Assisted Psychotherapy Help Improve Eating Disorder Symptoms?

I am a doctoral student at Alaska Pacific University conducting a research project in partial fulfilment of the requirements of the degree, Doctor of Psychology.  I am requesting your voluntary participation in my research.  Your full participation will require meeting with me for two 60-minute sessions, over the course of approximately 3 months.  You may choose to withdraw your participation at any time without penalty.

The objective of this study is to gather data on the impacts of ketamine assisted psychotherapy (KAP) on eating disorder symptoms to determine whether KAP is a feasible treatment for eating disorders.  Feasibility is different from effectiveness and efficacy, and the results of this study will be solely used to inform future researchers of appropriate study designs, participant numbers, and worthiness so that they may determine effectiveness or efficacy of KAP as an eating disorder treatment.

At the first meeting, I will gather your demographic information and KAP treatment details.  Then I will ask questions to measure the following things: hope, eating disorder symptoms, anxiety, depression, emotion regulation, and ketamine side effects.  The second meeting will take place after approximately 3 months of KAP treatment.  I will ask the same questions as the first meeting as well as questions to measure your satisfaction with and tolerability of KAP treatment.  After the last meeting, I will provide you with a summary of the information I have gathered from you and a list of resources.

Your personal health information (e.g. name and age) will be available only to myself during the lifespan of this research project.  All data gathered will be kept confidential and all data incorporated into the drafts and final reports of the research project will be free from any identifying information and will be HIPPA-compliant.  If specific responses are referenced, they will be referred to as coming from ‘participant A,’ for example.  If at any time you wish to no longer have your anonymous data included in the study, it will be promptly removed.  If at any time you have any questions about how this investigation is to be conducted, please contact me, Cassie Acres, at cacres@alaskapacific.edu

By signing on the line below I, _________________________, am indicating that I have read and understand the letter above, that I have been explained and offered a copy of the letter above, and that I have been offered the opportunity to discuss anything I did not understand.

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By signing on the line below, I am consenting to participate in this study and to my anonymous responses being used in data analysis for this study.

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By signing on the line below I acknowledge that I am at least 18 years of age, have a current or planned KAP treatment plan, and am not pregnant, have not experienced previous or current psychosis, and do not have a known risk of significant hypertension (i.e. high blood pressure).

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