Consent Form

Introduction:  My name is Jennifer Lewis. I am a doctoral student at Northcentral University in Arizona.  I am conducting a research study on how the attachment patterns of adults affect family closeness or distance within the family unit.   I am completing this research as part of my doctoral degree.  I invite you to participate.

Activities:  If you participate in this research, you will be asked to: 
1.      Review an informed consent form (approximately 3 minutes)
2.      Complete a brief demographic questionnaire (approximately 5 minutes)
3.      Select the most appropriate answer to questions regarding your personal family experiences (approximately 10 minutes) 

Eligibility:  You are eligible to participate in this research if you: 1.      Reside in the United States 2.      Are currently in a romantic relationship 3.      Are between the ages of 21 and 65 years You are not eligible to participate in this research if you: 1.      Reside outside of the United States   I hope to include 169 participants in this research.

Risks:  There are minimal risks in this study.  Some possible risks include: emotional distress when considering answers to questions about your family. To decrease the impact of these risks, you can: skip any item in the survey, and/or, stop participation at any time. 

Benefits:  If you decide to participate, although there are no direct benefits to you, the potential benefits to others are an improved understanding of family needs and hopefully improvement in future therapeutic services.

Confidentiality:  The information you provide will be kept confidential to the extent allowable by law.  Some steps I will take to keep your identity confidential are:   I will not ask for your name, and I will not collect any IP addresses. The people who will have access to your information are: myself, and/or, my dissertation chair. I will secure your information with these steps: locking the computer file with a password on my personal password protected computer. I will keep your data for 7 years. Then, I will delete electronic data and destroy paper data.

Contact Information: If you have questions for me, you can contact me at: My dissertation chair’s name is Dr. Richard Remedios.  He works at Northcentral University and is supervising me on the research.  You can contact him at: or (703) 779-0110 If you have questions about your rights in the research, or if a problem has occurred, or if you are injured during your participation, please contact the Institutional Review Board at: or 1-888-327-2877 ext 8014. 

Voluntary Participation: Your participation is voluntary.  If you decide not to participate, or if you stop participation after you start, there will be no penalty to you.  You will not lose any benefit to which you are otherwise entitled.

Participation can be anonymous.  You do not need to leave your name.  However, if you would prefer to give your name, you may type it in on the next page or choose to proceed anonymously.

Principal Researcher: Jennifer Lewis, MS         Contact Information:            Date: June 19, 2015
Participation can be anonymous.  You do not need to leave your name.  However, if you would prefer to give your name, you may type it in here or choose to proceed anonymously. To proceed anonymously, simply leave this field blank and proceed to the next question.

What is your gender?

What is your age?

Are you currently in a romantic relationship?

Important note regarding the term "family" in this survey:

This survey is examining relationships in your current family relationship that was established after adulthood (i.e., family of procreation). It is NOT examining your familial relationships from childhood (i.e., family of orientation). So as you answer each question please reflect only on your current/adult family relationship.

How would you describe your current family unit?

Please answer the following questions as they pertain to your current (adult) family unit with significant other and children.

If you are a parent of adult children no longer living at home, please use the preceding guidelines to briefly describe your family unit (e.g., biological, adopted, stepchild)

How long has your current family unit been living together (full or part-time) in the same household?



How many romantic relationships have you been involved in (lasting at least 2 years) before your current relationship? 

How many children are in your current family unit? 
(including children who reside with you part time, during certain times of the year, and children not in the household for whom you provide care or assistance)

Please note that this also applies to adult children not living within the household who are still a part of the family unit
What is the highest degree you earned?

What was your household income, before taxes and other deductions, during the past 12 months?

Which best describes your ethnicity?

The following statements concern how you feel in romantic relationships. We are interested in how you generally experience relationships, not just in what is happening in a current relationship. Respond to each statement by indicating how much you agree or disagree with it.

It helps to turn to my romantic partner in times of need.

I need a lot of reassurance that I am loved by my partner.

I want to get close to my partner, but I keep pulling back.

I find that my partner(s) don't want to get as close as I would like.

I turn to my partner for many things, including comfort and reassurance.

My desire to be very close sometimes scares people away.

I try to avoid getting too close to my partner.

I do not often worry about being abandoned.

I usually discuss my problems and concerns with my partner.

I get frustrated if romantic partners are not available when I need them.

I am nervous when partners get too close to me.

I worry that romantic partners won't care about me as much as I care about them.

Family members should complete this instrument independently, not consulting or discussing their responses until they have been completed.

Family members are involved in each others lives.

We get along better with people outside our family than inside.

We spend too much time together.

Family members feel very close to each other.

Family members seem to avoid contact with each other when at home.

Family members feel pressured to spend most free time together.

Family members are supportive of each other during difficult times.

Family members know very little about the friends of other family members.

Family members are too dependent on each other.

Family members consult other family members on important decisions.

Family members are on their own when there is a problem to be solved.

Family members have little need for friends outside the family.

Family members like to spend some of their free time with each other.

Our family seldom does things together.

We feel too connected to each other.

Although family members have individual interests, they still participant in family activities.

Family members seldom depend on each other.

We resent family members doing things outside the family.

Our family has a good balance of separateness and closeness.

Family members mainly operate independently.

Family members feel guilty if they want to spend time away from the family.

Thank you for taking the time to complete this survey!

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