CONSENT FORM

Effect of the Cretan Intuipath® finger labyrinth on ADHD-diagnosed children

You are invited to be in a research study to determine whether children diagnosed with ADHD combined type or ADD with Hyperactivity), who use both hands simultaneously to move through a mirror-image Cretan Intuipath® wood finger labyrinth design for a specified amount of time (3-5 times per week for 5 minutes each) will show a reduction in the behavioral symptoms associated with this condition (hyperactivity, impulsivity and inattention) over ADHD-diagnosed children who engage in a similar activity (moving both hands through a tray of sand) for the same amount of time.

You were selected as a possible participant because you are between the ages of 7 and 17, are on medication for this diagnosis or not, and have been given a diagnosis (by a qualified health practitioner) of ADHD combined type or ADD with Hyperactivity. I ask that you or your parent, school educator or therapist read this form and ask any questions you may have before agreeing to be in the study.

This study is being conducted nationally by: Neal Harris, MA, LCPC, DAPA

Procedures:

If you agree to be in this study, you will be provided with either a plain compressed wood Cretan Intuipath® design or a sand tray for the duration of the study and these are the following requirements of you and those who would be observing you:

A family member, school educator or therapist will need to supervise you either using a Cretan Intuipath® design or a sand tray (depending on which group you fall into), at the same time each day, 3-5 times per week for 5-minutes each, for a consecutive 4-week period.

An observational rating scale (ADHD-SRS) with 56 questions will need to be filled out completely on you (by a parent, school educator or therapist) before you begin the study, right after you complete the 4-week research period and then once more at 6 weeks to determine any continuing effects. The ADHD-SRS observational tool typically takes between 10-15 minutes to complete.

Benefits/Compensation:

The benefits to participation are: potential reduction in behaviors commonly associated with this diagnosis, which might mean better school performance, increased social abilities, higher self esteem etc. The tangible benefit for participating is that if you are randomly selected to be in a group that uses the Cretan Intuipath® design, you will get to keep it once the study is complete. If you are chosen to be in one of the sand tray groups, you will be shipped a new plain compressed wood Cretan Intuipath® finger labyrinth design to keep once we receive your completed paperwork.

Confidentiality:

All Participants’ identities and information will remain strictly confidential. Research results will be published in summary format with reference given to groups only.

Voluntary Nature of the Study:

Participation in this study is completely voluntary.

Contact Information and Questions:

The researcher conducting this study is: Neal Harris. You may ask any questions you have now, at anytime throughout the study as well as anytime after the study is complete. Here is my contact information: 26402 N. Edgemond Lane, Barrington, IL 60010, 847-842-1752,

relax4life@comcast.net.

Statement of Consent:

I have read the above information. I have asked questions and have received answers. I consent to participate in the study.

Signature of parent or guardian:____________________________________Date: ______________

Signature of Educator:____________________________________________Date: _____________

Signature of Therapist:____________________________________________Date: _____________

Signature of Researcher:___________________________________________Date: ____________

Child’s Name:__________________________________DOB:____/____/____Gender:_____(M/F)

Full Diagnosis:____________________________________________________________________

________________________________________________________________________________

Medication(s) with Dosages:_________________________________________________________