Informed Consent Form

Information

As part of my doctoral research, I am collecting

data concerning role
of Psychological

Flexibility on emotional adjustment and psychological well-being in individuals who have had

early traumatic experience. Information will be collected using questionnaires.This will require

30 minutes. The study will be done in groups inside the college premises. It will be
roughly
Permission
during free hours. Hence not with the
conducted it will interfere classes. to carryout

the study has been taken from the Principal and the respective class teacher. Questionnaire to be

filled given directly to the participant.

Undertaking by Investigator
Your consent to participate in the study is sought. You may or may not participate. You

may benefit from taking part in this study, as the responding to the questionnaire would help to

understand oneself better. The knowledge gained will benefit in increasing the scientific

knowledge in the researched area. You have the right to refuse consent or withdraw the same

during any part of the study without giving any reason. you have any doubts about the study
If

feel free to the same. The information obtained will be kept confidential and used
please clarify

only for research.

Consentfrom Parent
"I have read and understood about the study. give my consent
1,

to participate
in the study".

Signature of Participant Signature of Investigator

Date:

Place:
 SOCIODEMOGRAPHICDETAILS

Name: Date of Birth:

Age Sex: M/F Class: Education:

No of siblings: Birth Order:

Type of Family:

Presence of any
Joint/Nuclear/Extended

physical illness: Yes/No If Yes, Mention:

Dee Mons
Presence of any other mental illness: Yes/No If Yes, Mention: Pn
Presence of any physical disability: Yes/No If Yes, Mention:

Presence of grandparents: Y/N

Single Parent: Yes/No If Yes, Mention:

Locality: Rural/Urban/Semi urban

Socioeconomic Status:
Upper/Middle/Lower loeetitgr Stai Lect
Family history of mental illness: Y/N If Yes, Mention
 Multidimensional Psychological Flexibility Inventory (MPFI)

IN THE LAST TWO WEEKS... Never Rarely Occasionally Often Very

Often Always
TRUE TRUE TRUE TRUE TRUE
was receptive TRUE
to observing
I
unpleasant thoughts and
feelings without with them.
interfering
tried to make peace with my negative and
I
thoughts
feelings rather than resisting them O O
made room to experience and
I
fuily negative thoughts
emotions, them O
When I
breathing
had an
in rather than
pushing them away O
upsetting thought or emotion, tried to give it I
space rather than ignoring it O O
opened myself to all of my
feelings, the good and the bad O O
I
Never Very
IN THE LAST TWO WEEKS... Rarely Occasionally Often
Often Always
TRUE TRUE TRUE TRUE TRUE
TRUE
was attentive and aware my emotionss
of O
I
was in
tune with my thoughts and feelings from moment to
moment
paid close attention to what was thinking and feeling O
I
I
was in touch with the ebb and flow of my thoughts and
I
feelings O
strived to remain mindful and aware of my own
I
and emotions
thoughts
O O

Never Often Very

IN THE LAST TWO WEEKS.. Rarely Occasionally
Often Always
TRUE TRUE TRUE TRUE TRUE
TRUE
Even when felt hurt or upset, I tried to maintain a broader
I
perspective
O
I carried myself through tough moments by seeing my life
from a larger viewpoint
O
I tried to keep perspective
even when life knocked me down
When Iwas scared or afraid, still tried to see the larger
O
I
picture O O
When something painful happened. tried to take a
I
balanced view of the situation O

Never Rarely Often Very

IN THE LAST TWO WEEKS... Occasionally Always
Often
TRUE TRUE TRUE TRUE TRUE
TRUE
able let come and gowithout
was to negative feelings
O
getting caught up in them
When I was upset, was able to let those negative feelings
O
I
pass through me without clinging to them
was able to gently experience
When I was scared or afraid, O
I
those feelings, allowing them to pass
was able to step back and notice negative thoughts and
O
I
feelings without reacting to them
O
was able to notice my thoughts and
In tough situations, I
feelings without getting overwhelmed by them
O O
 Very
IN THE LAST TWO WEEKS.. Never Rarely Occasionally Often
Often
Always
TRUE TRUE TRUE TRUE TRUE
TRUE
was very in-touch with what is
important to me and my life O
i stuck to my deeper priorities in life O
tried to connect with what is to me on a
I
truly important
daily basis O
Even when it meant
making tough choices, Istill tried to
prioritize the things that were important to me O O
My deeper values consistently gave direction to my life O O

Very
IN THE LAST TWO NEEKS.. Never Rarely Occasionally Ofter
Often
Aiways
TRUE TRUE TRUE TRUE TRUE
TRUE
Even when Istumbled in my efforts, I didn't quit working
toward what is important
O O
Even when times got tough, was stll able to take steps O
I
toward what I value in life
Even when life got stressful and hectic, still worked toward
O O O
I
things that were important to me

didn't let set-backs slow me down in taking action toward

O O O
I
what really want in life
I
Ididn't let my own fears and doubts get in the way of taking O
action toward my goals

Very
Never Rarely Occasionally Often Always
IN THE LAST TWO WEEKS... TRUE TRUE TRUE TRUE
Often
TRUE
TRUE
When hada bad memory, tried to distract make O
myselfto
I
I
it go away

tried to distract myself when felt unpleasant emotions

l
I
When unpleasant memories came to me, tried to put them O O O
I
out of my mind
When something upsetting came up, tried very hard to stop
O
I
thinking about it
there was something didn't want to think about, would
O O O O O
I
If
I
try many things
to get it out of my mind

Very
Never Rarely Occasionally Often Always
Often
IN THE LAST TWO WEEKS... TRUE TRUE TRUE TRUE TRUE
TRUE

most on "automatic"with awareness of what O O

Idid things
little

was doing.
O
I
most things mindlessly without paying much attention
did
1
went through most days on auto-pilot without paying much O
I
attention to what was thinking or feeling
O
I
floated through most days without paying much attention. O
I
Most of the time was just going through the motions O O O
I
without paying much attention
 Very Always
Often
Never Rarely Occasionally Often TRUE
THE LAST TWO WEEKS... TRUE TRUE TRUE TRUE
IN TRUE
or inappropriate
Ithought some of my emotions were bad
and I shouldn't feel them
irrational or inappropriate O O O
criticized myself for having
I
emotions
are abnormal or bad and
some of my
I
believed thoughts
I
shouldn't think that way
told myself that shouldn't be feeling the way I'm feeling
I
oo
I
told myself shouldn't be thinking the way was thinking
I
I
I
Ver
Often Always
Never Rarely Occasionally Often
TRUE TRUE TRUE
IN THE LAST TWO WEEKS... TRUE TRUE TRUE
and feelings tended to stick with me for a O O
Negative thoughts

long time.
Distressing thoughts tended to spin around in my mind ike a O
broken record.

It was very easy to get trapped into unwanted thoughts and

O O O
feelings
was hard to
O O
When had negative thoughts or feelings very
it
I
see past them.
When something bad happened was hard for me to stop O O O
it
thinking about
it.
Very
Never Rarely Occasionally Often Always
Often
IN THE LAST TWO WEEKS.. TRUE TRUE TRUE TRUE TRUE
TRUE

My priorities and values often fell by the wayside in my day O O

to day life

lost touch with the things value O O

When life got hectic, often I
I
The things that I value the most often fell off my priority list
O O
completely
are
didn't usually have time to focus on the things that
O
I
really important to me
When times got tough, was easy to forget about what O O O O
it
truly value

Very
Never Occasionally Ofter Always
Rarely Often
IN THE LAST TWO WEEKS.. TRUE TRUE TRUE TRUE TRUE
TRUE
O O
Negative feelings often trapped me in inaction

Negative feelings easily stalled out my plans

O
Getting upset left me stuck
and inactive
derailed from what's me really
O
Negative experiences

important
Unpleasant thoughts and feelings easily overwhelmed my O O O
efforts to deepen my life
 Adverse Childhood Experience (ACE)Questionnaire
Finding your ACE Score a 1024 hbr 06

While you were growing

up, during your first 18 years of life:

1. Did a parent or other adult in the household often ...

Swear at you, insult you. put you down, or humiliate you?
or
Act in a way thatmade you afraid that you might be physically hurt?
Yes No If yes enter

I
2. Did a parent
Push,
or other adult in the household

grab, slap, or throw something at

often

you?
.
or
Ever hit you so hard that had marks or were injured?
you
Yes No If yes enter

3. Did an adultor person at least 5

years older than you ever...
Touch or fondle you or have
you touch their body in a sexual
way?
or
Try to or actually have oral, anal, or
vaginal sex with
you?
Yes No If yes enter 1

4. Did you often feel that...

No one in your family loved you or
thought you were important or special?
or
Your family didn't look out for each other, feel close to each other, or support each other?
Yes No If yes enter 1

5. Did you often feel that...

You didn't have enough to eat, had to wear dirty clothes, and had no one to protect you?
or
Your parents were too drunk or high to take care of you or take you to the doctor if you neededit?
Yes No If yes enter 1

6.Were your parents ever separated or divorced?

Yes No Ifyes enter
7. Was your mother or stepmother:
Often pushed, grabbed, slapped, or had something thrown at her?
or
Sometimes or often kicked, bitten, hit with a fist, or hit with something hard?
or
Ever repeatedly hit over at least a few minutes or threatened with a gun or knife?
Yes No If yes enter
1
8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?
Yes No If yes enter 1

9. Was a household member depressed or mentally ill or did a household member attempt suicide?
Yes No Ifyes enter
10. Did a household member go to prison?
Yes No If yes enter
1
Now add up your "Yes"answers: This is your ACE Score
 PCL-5

Instructions: Below a is problems that people sometimes have in response to a very stressful experience. Please
list
of

then one of the numbers to the right to indicate how much you have been
ead each problem carefully
bothered
and circle
by that problemin the pastmonth.

In the past month,how much were Not at little

you bothered by: derately Extremely
all bit a bit
1.
Repeated, disturbing, and unwanted memories of the
stressful experience?

2.
Repeated, disturbing dreams of the stressful experience?

Suddenly feeling or acting as if the

experience were
stressful
actually happening again (as you were actually back there
2
if
reliving it)?

4.
Feeling very upset when something reminded you of the
stressful
experience? (0 (1 2 4

5.
Having strong physical reactions when
something reminded
you of the stressful experience (for
example, heart
pounding., trouble breathing, (4
sweating)?
6.
memories, or

7.
Avoiding
stressful experience?
thoughts,

external reminders
feelings related to the
(2 3
Avoiding of the stressful
experience (for
example, people, places, conversations, activities,
objects, or
situations)? (2 (3 4

Trouble

9.
remembering
experience?
important parts of the stressful
2 (4
Having strong negative beliefs about
yourself, other people
or the world (for example,
having thoughts such as: I am
bad, there is something
seriously wrong with me,
no one can be trusted, the world is
completely dangerous)?
10. Blaming
yourself or someone else for the stressful
experience or what happened after it?
11. Having

guilt, or
strong negative
shame?
feelings such as fear, horror, anger,
(2 3 (4
12. Loss of interest in activities that you used to enjoy?

13. Feeling distant or cut

off from other people? (T 4
14. Trouble experiencing positive feelings (for example, being
unable to feel happiness or have loving feelings for people
close to you)?
2
15. Irritable behavior, angry outbursts, or acting aggressively? 4
16.
Taking
harm?
too many risks or doing things that could cause you
2
17. Beingsuperalert" or watchful or on guard? 2

-
18. Feeling

Having
jumpy or easily startled?

difficulty concentrating? (0
(1 (2

19.
20. Trouble falling or staying asleep?

PCL-5 (11 April 2018) National Center for PTSD Page1 of1
 DASS 21 NAME E
DATE RLACKDX INSTITI

Please read each statement and circle a number 0,1, 2or 3which indicates how much the statement appiied to you
over the past week. There are no right or wrong answers. Do not
The spend too much time on any statement.
rating scale is as
follows:
0 Did not
apply to me at all NEVER
1 Applied to me to some degree, or some of the -
2 Applied time SOMETIMES
to me to a considerable
degree, or a good part of time -
3 Applied to me very much,or
OFTEN
most of the time ALMOST ALWAYS
FOR OFFICE USE

I
found it hard to wind down
NS 0 AA D A

|I was aware of
dryness of my mouth
3 I
couldn't seem to
experience any positive feeling at all
l
4 experienced breathing difficulty (eg, excessively
breathlessness in the absence rapid breathing.
of
physical exertion)
5 Ifound it difficult to work
up the initiative to do things
6 I tended to over-react to
situations

experienced
I
trembling (eg, in the hands)

8 felt thatI was using a

I
lot of nervous
energy

was worried about

I
9 situations in which
might panic and make a fool
I
myself of

10 I felt that I had

nothing to look forward to

11 I found
myself getting agitated

12 1 found it difficult to relax

13 1felt down-hearted and blue

|I was intolerant of anything that kept me from

14 getting on with what was
I
doing

15 I feltI
was close to panic

16 Iwas unable to become enthusiastic about anything

L
17 I felt Iwasn't worth much as a person

18 I felt that I was rather

touchy

was aware my
19 of the action of heart in the absence of physicalexertion (eg,
sense of heart rate increase, heart missing a beat)

20 I felt scared without

anyeood reason

21
Ifelt that life was meaningless

TOTALS