Listening Circle Consent Form
Appalachian shOUT, which stands for Appalachian Sexual Health Outreach, is a collective impact initiative that aims to engage community systems to support youth wellbeing and sexual health. Listening Circles are the first step in this work.

Listening Circles give participants a chance to share their lived experience without contradiction or judgment. They support honesty and nurture compassion in an atmosphere of safety and equity. We hope they will help us better understand the needs of Appalachian youth and how we can all empower them with information and support to make informed decisions about their health.

Listening circles may take place in community or organizational settings. Youth can expect open ended questions about the challenges, barriers, and messages they experience about sexual and overall health. No youth will be forced or pressured to answer any questions they are not comfortable with, and no direct questions will be asked about their own behaviors. If you would like to receive a copy of the questions being asked, or have any other questions, please contact Josh Diamond at diamonjn@jmu.edu, or 540-830-2721

Participation in the listening circles is completely voluntary and confidential. Participants may leave the session at any point if they are uncomfortable. Notes will be taken during the session; however, no personally identifying information will be recorded. Lessons learned and themes from the listening sessions will be included in the final listening project report.

All of the responses that are given as part of the listening circle will be kept private. They will only be available to people involved with the project, except when required by law. There are two exceptions: 1) if your child/you reveals that they are a danger to themselves or others; 2) if they/you reveal abuse committed against a child. In either of these cases, we must report it to the appropriate authorities.

By signing this consent form, you are letting us know that you have read the form and are at least 18 years of age. You have asked any questions you have about the project, and you give consent for your child/you to participate in the Shout Listening Project Youth Listening Circle.
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Name of participant *
City participant lives in *
State participant lives in *
Age of participant *
What Listening Circle is the participant attending? *
Name of guardian (if participant is less than 18 years old). Write "n/a" if this does not apply *
I have read this form and am at least 18 years old. I had an opportunity to ask any questions I have about the Listening Project, and I agree that my child/myself may participate in an Appalachian shOUT Listening Circle. *
Date *
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