I______________________________(the undersigned) have been informed about the possible use of written practice exercises about hurt feelings as homework assignments, either by themselves written at a distance (by mail, fax, or Internet), or as additions to other verbal, face-to-face professional approaches like promotion, prevention, psychotherapy, or rehabilitation.

I understand that this approach is still experimental and needs to be evaluated before being available to everybody. I am aware of the possible dangerous consequences that may be provoked by answering written practice exercises about hurt feelings at a distance. I agree to participate in this type of intervention with full understanding that it may bring up painful memories of my past and that this approach, at least initially, may produce some upset for me, my partner, or my family. I understand further that all information about me will be considered absolutely confidential because all of my writing will be limited between myself and the professional who is administering these written homework assignments. To maximize this anonymity, I can use the following five-digit number instead of my name in completing practice exercises.