INFORMED CONSENT FORM

Participant ID:______________

You are invited to participate in a research study that I am conducting as a requirement for my
BS Psychology degree at University of Karachi. The purpose of this study is to examine the
relationship between early life experiences and current mental health.

Your participation in this study is voluntary and you may choose not to participate or withdraw
from the study at any time without penalty. The following information is provided to help you
make an informed decision about your participation.

Procedures: If you agree to participate, you will be asked to complete a survey questionnaire
that will take approximately 15-20 minutes to complete. To protect your anonymity, you will not
be asked for your name and instead will be assigned a unique identifier number.

Risks and Benefits: There are no known risks associated with participating in this study. It is
possible that some questions may elicit uncomfortable memories or emotions. The potential
benefits of participating in this study include contributing to the understanding of the relationship
between early life experiences and mental health outcomes and potentially improving mental
health services for individuals who have negative early experiences.

Confidentiality: All survey responses will be kept confidential and anonymous. Your name will
not be collected and a unique identifier number will be assigned to you instead. Your information
will be stored securely and only the researcher and the supervisor will have access to the data.
No identifying information will be shared or published in any form.

Compensation: There is no compensation for participating in this study.

By signing below, you indicate that you have read the information provided and you agree to
participate in the study voluntarily.

Participant Signature: ________________ Researcher signature:______________

Date: _____________

Thank you for considering participating in this study.

● Gender
Male
Female
Other

● Age _____________

● Birth order ________

● Education _________

● Family structure
Nuclear
joint

● Average income
20-40 thousand
41-60 thousand
61-80 thousand
81-100 thousand
More than 1 lac

● Marital status
Single
Married
Separated
Widow
Widower
These questions ask about some of your experiences growing up as a child and a teenager. For each question, circle
(or select in any other way if completing online) the number that best describes how you feel. Although some of these
questions are of a personal nature, please try to answer as honestly as you can. Your answers will be kept
confidential.

Q QUESTION NEVER RARELY SOMETIMES OFTEN VERY

TRUE TRUE TRUE TRUE OFTEN
TRUE
When I was growing up
1 I didn't have enough to eat. 1 2 3 4 5
2 I knew that there was someone to take care of me 1 2 3 4 5
and protect me.
3 People in my family called me things like "stupid", 1 2 3 4 5
"lazy", or "ugly".
4 My parents were too drunk or high to take care of 1 2 3 4 5
the family.
5 There was someone in my family who helped me 1 2 3 4 5
feel important or special
6 I had to wear dirty clothes 1 2 3 4 5
7 I felt loved. 1 2 3 4 5
8 I thought that my parents wished I had never been 1 2 3 4 5
born
9 I got hit so hard by someone in my family that I had 1 2 3 4 5
to see a doctor or go to the hospital.
10 People in my family hit me so hard that it left me 1 2 3 4 5
with bruises or marks.
11 I was punished with a belt, a board, a cord (or some 1 2 3 4 5
other hard object).
12 People in my family looked out for each other. 1 2 3 4 5
13 People in my family said hurtful or insulting things to 1 2 3 4 5
me.
14 I believe that I was physically abused. 1 2 3 4 5
15 I got hit or beaten so badly that it was noticed by 1 2 3 4 5
someone like a teacher, neighbour, or doctor.
16 Someone in my family hated me. 1 2 3 4 5
17 People in my family felt close to each other. 1 2 3 4 5
18 Someone tried to touch me in a sexual way or tried 1 2 3 4 5
to make me touch them.
19 Someone threatened to hurt me or tell lies about 1 2 3 4 5
me unless I did something sexual with them.
20 Someone tried to make me do sexual things or 1 2 3 4 5
watch sexual things.
21 Someone molested me (took advantage of me 1 2 3 4 5
sexually).
22 I believe that I was emotionally abused. 1 2 3 4 5
23 There was someone to take me to the doctor if I 1 2 3 4 5
needed it
24 I believe that I was sexually abused. 1 2 3 4 5
25 My family was a source of strength and support. 1 2 3 4 5
Please read each statement and circle a number 0, 1, 2, or 3 which indicates how much the statement applied
to you over the past week. There are no right or wrong answers.
Do not spend too much time on any statement. The rating scale is as follows:
0 Did not apply to me at all
1 Applied to me to some degree or some of the time
2 Applied to me to a considerable degree or a good part of the time
3 Applied to me very much or most of the time.

1 I found it hard to wind down 0 1 2 3

2 I was aware of dryness of my mouth 0 1 2 3
3 I couldn’t seem to experience any positive feeling at all 0 1 2 3
4 I experienced breathing difficulty (e.g., excessively rapid breathing, 0 1 2 3
breathlessness in the absence of physical exertion)
5 I found it difficult to work up the initiative to do things 0 1 2 3
6 I tended to over-react to situations 0 1 2 3
7 I experienced trembling (e.g., in the hands) 0 1 2 3
8 I felt that I was using a lot of nervous energy 0 1 2 3
9 I was worried about situations in which I might panic and make a fool 0 1 2 3
of myself
10 I felt that I had nothing to look forward to 0 1 2 3
11 I found myself getting agitated 0 1 2 3
12 I found it difficult to relax 0 1 2 3
13 I felt down-hearted and blue 0 1 2 3
14 I was intolerant of anything that kept me from getting on with 0 1 2 3
what I was doing
15 I felt I was close to panic 0 1 2 3
16 I was unable to become enthusiastic about anything 0 1 2 3
17 I felt I wasn’t worth much as a person 0 1 2 3
18 I felt that I was rather touchy 0 1 2 3
19 I was aware of the action of my heart in the absence of physical 0 1 2 3
exertion (e.g., sense of heart rate increase, heart missing a beat)
20 I felt scared without any good reason 0 1 2 3
21 I felt that life was meaningless 0 1 2 3