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Participant Consent Forms

Relationship Between Differentiation and Infidelity Amongst the Iranian-American Population

California School of Professional Psychology at Alliant International University – Los


This is a very important form, please read it very carefully before proceeding to the survey.

Purpose of the Study:

This is a psychological study that is being conducted by Natasha Behnam, a student under the direct supervision of Dr. Susan Regas at Alliant International University. The purpose of this study is to examine the relationship of differentiation on future romantic relationships.


What will be done:
You will complete a survey, which will take approximately 20 minutes to complete. The survey includes questions about your behaviors and feelings in various relationships You will also be asked about the nature of your relationships with your parents, romantic partners and the inner thought processes involved regarding thes relationships.


Benefits of this Study:

You will be contributing to knowledge about how each person’s relationship with their family of origin affecttheir current romantic relationships. Specifically, you will help specify arenas in which particular ways ofthinking and feeling can be related to deleterious behaviors in relationships, such as infidelity. Additionally,your response will expand information related to cross-cultural applications of psychology, thus enabling current and future clinicians to provide more culturally competent forms of treatment.


Risks or discomforts

While no physical or legal risks are embedded within this research project, some participants are answering questions about personal relationships that may incur emotion discomfort. Specifically, strained relationships with romantic partners and fathers may trigger emotional turmoil. If you become aware of emotional discomfort and do not want to continue the study, it is suggested that you exit thescreen and contact the principal investigator if desired. If you decide to quit at any time before you have finished the questionnaire, your answers will NOT be recorded. Additionally, participants who do not complete the entirety of the questionnaire will not be considered for the raffle. If you are to feel uncomfortable during the study and require immediate assistance, you can contact the investigator at: for a therapy referral, the supervising investigator at,or call the Valley Trauma Center at (818) 756 –5330,a nation wide 24 hour hotline.



Your responses will be kept completely confidential and anonymous. We will NOT know your IP address when you respond to the Internet survey. All identifying information (email address) will be kept separate from the data in a secure file. All recorded data will be destroyed in accordance with Alliant International University policy within 5 years of collection.


Decision to quit at any time:

Your participation is voluntary; you are free to withdraw your participation from this study at any time. If you do not want to continue, you can simply leave this website. If you do not click on the "submit" button at the end of the survey, your answers and participation will not be recorded.


How the findings will be used:

The results of the study will be used for scholarly purposes only. The results from the study will be presented in educational settings and at professional conferences, and the results might be published in a professional journal in the field of psychology.


Contact information:

If you have concerns or questions about this study, please contact the principal investigator, Natasha Behnam at or her direct supervisor, Dr. Susan Regas at For any questions regarding the general rights of research participants you may contact the Office for Human Research Protections at


Please mark the boxes below accordingly:

I would like a copy of the results of this study when it is completed

I have read all of the above information regarding this study and understand what it says.

(a) I am at least 22 years of age 

(b) I am currently in an exclusive relationship 

(c) I am able to read and write English 

(d) I am able to read and understand the consent form and 

(e) I voluntarily agree to participate in this research project by checking the “I accept” button below.