SRRT Follow-Up Study

You are invited to complete a brief screener to see if you are a good fit for this study. Participation is voluntary. You may pause or stop at any time without penalty.

Privacy and safety

Your responses are confidential and stored securely on a secure, HIPAA-enabled platform.
This form is not monitored in real time and does not provide clinical care. If you need immediate help, call 911 or text or call 988.
If you do not qualify, we delete your identifiable screening data within 7 days of determination.

Purpose
This brief screener confirms eligibility for a one-time written reflection about your experience with Self-Reflective Relationship Therapy, SRRT.

Privacy
Your responses are confidential, stored securely on a HIPAA-enabled platform, and used only to assess eligibility.

Thank you for considering to join this study.

Full Name:

Email address

Phone Number

Are you 18 years of age or older?

Yes No

Are you comfortable reading and writing in English well enough to complete a one-time written reflection, about 20 to 30 minutes, without assistance?

Yes No

Have you been in a heterosexual marriage or relationship for at least 4 years, with at least 1 year living together?

Yes No

Your SRRT History

Did you complete the six-week SRRT workbook 6 to 18 months ago?

Yes No

Did you finished at least 5 of the 6 weeks?

Yes No

Values and Fit

Do you identify as Christian?

Yes No

Current Services

Are you currently attending couples therapy or another structured relationship program?

Yes No

Are you a current or former clinical clients of Ehsan Adib Shabahang at AtReef Therapy PLLC or personally known to the principal investigator?

Yes No

Note: Selecting 'Yes' will make you ineligible for this study.

Safety Screen

Are you experiencing any mental health or substance use crises that might make reflective writing stressful and potentially overwhelming?

Yes No

Do you currently have a restraining order or history of intimate partner violence in this relationship?

Yes No

Note: Selecting ‘current or past intimate partner violence,’ or ‘a restraining order will make you ineligible for this study. Selecting ‘a mental‑health or substance‑use crisis’ indicates it may not be a good fit right now.

Consent to be Contacted

If eligible, may we email you the consent form and next steps?

Yes No

Acknowledgment

By submitting this form, I confirm the information provided is accurate to the best of my knowledge. I understand that my information will be reviewed for eligibility and handled confidentially.

I agree I do not agree

What happens next

If eligible, you will receive a secure email with consent materials and instructions.

Privacy and safety: If you do not qualify or not eligible for this study, your identifiable screening information and data will be deleted within 7 days.

If you need support now

911, emergency services
988 Suicide and Crisis Lifeline, call or text 988, 988lifeline.org
National Domestic Violence Hotline, 1-800-799-SAFE, thehotline.org
SAMHSA National Helpline, 1-800-662-HELP

Your privacy is protected. Screening responses are stored securely, used only for eligibility review, and never shared outside the research team.

Your information will be encrypted.