Rocky Mountain College

1511 Poly Dr.

Billings, MT 59102

Department of Occupational Therapy

Occupational Identity and Mental Well-Being in Teen Moms Program

Principal Investigator: Co-Principal Investigators

Madalyn Martin Johanna Thompson, OTR/L
Doctorate Student of Occupational Therapy Professor and Practitioner specialized in
Madalyn.martin@rocky.edu NICU care
(281) 450-3854 Johanna.thompson@rocky.edu

Statement of Consent

We are asking you to participate in a program titled “Occupational Identity and Mental Well-Being in Teen
Moms” We will describe this program to you and answer any questions. This program is being led by the
Occupational Therapy Doctorate Program, a Department of Rocky Mountain College.

This form should take you no longer than 10 minutes to complete.

What the Program is About

The purpose of this program is to create a supportive group of teen moms and work through the relationships
between mental well-being and confidence to be a mom, friend, and daughter. This information will be used to
give advice for future programs to create holistic approaches for addressing the mental well-being of teen moms
in rural areas, like Wyoming.

What We Will Ask You to Do

First, you will be asked to complete a Google Forms survey. After the survey, you will be asked to participate in
a support group with other teen moms led by the occupational therapy student.

The Survey
The survey consists of 3 different assessments that will help give the group leader an idea about who you are.
This will include how you feel about your day-to-day life and your roles as a mother and student.
This should take you no longer than 10 minutes.

Interview
You will be asked to participate in an informal interview to talk about the experiences of the support group.
This will be no longer than 10 minutes.

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You can join any part of the project. Going to the support groups does not that require you to be interviewed.
This project is completely voluntary.

Risks and Discomforts

Participation in this program is voluntary and should only be performed if personal safety can be assured. You
may be asked to answer questions related to their occupations and mental well-being that may create
uncomfortable feelings spurred on by unpleasant memories, past illnesses, or personal struggles. Individuals
going through an adverse event or crisis may be referred to local resources provided by the group leader. You
will be given a brief instruction to cover “Ethics and Safety” to ensure safe conditions.

Benefits
You may experience a direct benefit from the support of local organizations and other teen moms. The
development of relevant coping strategies that reduce negative feelings or emotions will also be a benefit to the
support groups. Possible indirect benefits include reflecting on topics that may lead to a better understanding of
one’s own person or outlook on life. It is hopeful this program will provide information that may be used to
ease the transition of roles that teen moms take on and provide an understanding of what supports teen moms
and where they can go to get this support. In addition, we hope to learn how communities can better understand
the individual and their shared, cultural characteristics.

Mental health resources and affordable medical information will be shared by the first support group meeting.

Compensation for Participation

Compensation will be available for you in the support group portion of the program. You must complete the
survey, and at least two support group meetings, and participate in the interview that takes place after all of the
support group meetings to receive compensation.
The compensation will be gift cards from local stores and organizations. These will be retrieved by donations
from organizations such as Sidekicks Bookbar, Stellar Cellar, Apricot Lane, and local coffee shops.

Taking Part is Voluntary

Being in this program is entirely voluntary and is up to your decision if you want to participate. You may
choose to withdraw from the program at any time without penalty. During the program, you can also choose to
skip any questions or procedures that you feel are uncomfortable or unnecessary. Any questions related to this
program can be answered by the group leader to clarify instructions or issues.

Completion of all questionnaires and interviews is suggested, but not required, to be a part of the program. The
extent to which you want to be a part is up to you.

The Option to Opt-Out

You can opt out of the program at any point. There will be no requirement to further contact to confirm the
option to opt-out.

Time Commitment
You will be asked to take a 15-minute survey, attend 7 support groups between 30-45 minutes each, and have a
10-min “exit” interview to talk about your experience with the support groups.

Audio Recording
Support groups will be audio-recorded and transcribed (written down word for word) to give the group leader a
chance to reflect on the conversation and experiences without any misunderstanding.

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Given that the Principal Investigator is an Occupational Therapist student, accommodations will be made for
mental and physical disabilities to increase involvement in all aspects of the program.

Audio recordings will be taken from interview sessions to allow for playback and note common repeated
phrases. All recordings will be deleted following the completion of the program and all of your information will
be kept confidentially coded. Only the group leader of the program will have access to the recordings. After the
sessions are transcribed, these documents will be permanently deleted in one year.
By signing below, you are willing to have the support group sessions and personal interview audio recorded.

The audio recording is voluntary, and you can opt out of the recording at any time.
You may still participate in this program if the recording option is declined.

Are you willing to have the audio of your personal interview recorded by the group leader?

I am willing to have this interview recorded.

I do not want to have this interview recorded.

Legal Guardian Signature: _______________________________

Participant Signature:
Date:

Organization of Support Groups:

This project will consist of 7 group meetings with a length of 30-45 minutes each. The following session and
topics are listed below.

Session: Topic: Permission to audio record:

 Icebreaker Activity
One  Mindfulness Activity
[Week 1]  What Occupational Therapy is
 What Mental Well-Being is
I am willing to have this group
audio recorded.
I do not want to have this group
audio recorded.

Legal Guardian Signature:

____________________________
Participant Signature:
_____________________
Date: ___

 Mindfulness Activity I am willing to have this group

 Mental well-being: what are we doing
Two to take care of our mental health?
[Week 2] What are some ways we can better our
mental health?
 Activity: Learning mindfulness with
yoga and journaling.
 Education: On local and national
resources for mental health; learning
how to maintain personal mental
audio recorded.
I do not want to have this group
audio recorded.
Legal Guardian Signature:
____________________________
Participant Signature:
_____________________

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 health. Date: ___

 Mindfulness Activity I am willing to have this group

 Defining our Roles: as a mother, audio recorded.
daughter, friend, and student.
 Occupational Balance: Defining and I do not want to have this group
exploring audio recorded.
Three  Activity
[Week 3]  Education: On local and national Legal Guardian Signature:
resources for maintaining these roles. ____________________________
Participant Signature:
_____________________
Date: ___

 Mindfulness Activity I am willing to have this group

 A “Check-In” audio recorded.
 Life Skills: getting and maintaining a
job; doing high school and/or college I do not want to have this group
Four  Activity: Looking up what schools and audio recorded.
[Week 4] jobs are interesting and how to achieve
them Legal Guardian Signature:
 Education: How to navigate websites ____________________________
such as Indeed, LinkedIn, and School Participant Signature:
programs _____________________
Date: ___

*Last 3 weeks are  Mindfulness Activity I am willing to have this group

subjective to change due  Trauma: Understanding how past audio recorded.
to adhering to the
participants desires to
trauma can affect our lives and how to
discuss and practice. * heal from trauma. I do not want to have this group
 Coping Skills audio recorded.
Five  Activity: Trauma worksheet,
[Week 5] navigating feelings Legal Guardian Signature:
 Education: Zones of Regulation ____________________________
Participant Signature:
_____________________
Date: ___

 Mindfulness Activity I am willing to have this group

 Communication Skills: How to audio recorded.
Six communicate wants and needs; ask for
[Week 6] respect I do not want to have this group
 Activity: Communication game audio recorded.
 Education: Hands outs/prompts for
communication skills and starters Legal Guardian Signature:
____________________________
Participant Signature:
_____________________
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 Date: ___

 Mindfulness Activity I am willing to have this group

 A “Check In” audio recorded.
Seven  Healthy Relationships: How to create
[Week 7] and maintain healthy relationships I do not want to have this group
 Activity: “Draw a healthy relationship” audio recorded.
 Closing
Legal Guardian Signature:
____________________________
Participant Signature:
_____________________
Date: ___

** If you decide to change your mind about any of these audio-recording preferences, a sheet will be
available to sign and change on the day of the support group meeting.

Privacy/Confidentiality/Data Security
Your specific data will be held on the group leaders’ Google Drive accessed through Rocky Mountain College’s
secure servers and held under password protection. Information that is unique to you will be de-identified
during all uses and shared information. This means fake names or numbers will be used to cover your identity.
Submitted data will be stored per person and will remain available only to involved group leaders. Data may
exist on backups and server logs beyond the timeframe of this program.

Electronic copies of these documents will remain within Google Drive within Rocky Mountain College’s secure
servers. Public use of any media or correspondence will be further de-identified.

I anticipate that participation in the Google Forms survey presents no greater risk than everyday use of the
Internet.

Please note that email communication between you and group leader is neither private nor secure. Though we
are taking precautions to protect your privacy, please be aware that information sent through email could be
read by a third party.

Sharing De-identified Data Collected

De-identified data from this program may be shared with the research community to help improve awareness of
needs in science and health. We will remove or code any personal information that could identify you before
files are shared with other researchers to ensure that no one will be able to identify the participant from the
information we share. Despite these measures, we cannot guarantee the anonymity of your personal data.
However, the information shared will have no links to your personal information (i.e., name, address, etc.)

Future Use of Identifiable Data or Specimens Collected

Identifiable information might be used for future research by obtaining you and your legal guardian’s consent.

If You Have Any Questions:

The main group coordinator conducting this program is Madalyn Martin, a student at Rocky Mountain College.
Please ask any questions as soon as possible. If you have questions later, you may contact Madalyn Martin at

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Madalyn.martin@rocky.edu or at (281) 450-3854. If you have any questions or concerns regarding your
rights as a subject in this program, you may contact the Institutional Review Board (IRB) for Human
Participants at https://www.rocky.edu/resources/faculty-tools/institutional-review-board
(lucas.ward@rocky.edu)

Statement of Consent

I have read the above information and have received answers to any questions I asked. I consent to take part in
the program.

Legal Guardian Signature Date

The Participant (printed)

Participant Signature Date

The Participant (printed)

Signature of the person obtaining consent Date

Printed name of person obtaining consent

Proof of address by the participant and legal guardian was provided.

Proof of address by the participant and legal guardian was not provided.

This consent form will be kept by the student for five years beyond the end of the program.

A copy of this Consent Form will be given to participants upon request.

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