Multicultural Counseling and Advocacy

Consent Form

Multicultural Counseling and Advocacy

This letter is an invitation to participate in a field assignment that I am required to complete in my Multicultural Counseling and Advocacy course at Argosy University. The course instructor is (Insert Faculty’s Name) and can be contacted at (insert phone number and email) if you have questions or concerns at any time.

The focus of this project is for me to learn about different cultures. The project will help me learn more about your culture so I can become a more culturally competent clinical mental health counselor. You participation is voluntary and you may withdrawal your consent, without penalty, at any point during the project by telling me that you no longer wish to participate. Please know that this is not a research study, but a field assignment. I am required to conduct an interview with someone from your culture and to observe and interact, as appropriate, at a cultural event. The experiences will be shared in a paper and turned into the instructor of this course, as a requirement for this project. In addition, the experience may also be shared in class discussion. You may request a copy of this paper at any time by contacting me. For confidentiality purposes, you may choose to remain anonymous and to ask that particular information be withheld from the paper. If you choose to remain anonymous, a fictitious name will be used to protect your identity.

In addition to the information provided above, I am available to provide you with more information about this project and what your involvement would entail if you decide to take part.

Name of the student: _____________________________________________________________________

Date on which the project was begun: ______________________________________________________

Estimated duration of the project: __________________________________________________________

Statement of Purpose of the project: In order to more fully understand a multicultural group of which the student is not a member, the student will engage with a group and conduct an interview of a cultural guide.

Confidentiality clause: Information from this field experience will be used in a written paper about the assignment thus confidentiality cannot be guaranteed. However, steps can be taken to give the participant(s) more annonominity such as changing the identifying information and withholding information at the direct request of the participant(s).

__________________________________ ______________________________

Interviewee’s written name Interviewee’s signature

_________________________________ ______________________________

Student’s written name Student’s signature


Date of the interview

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