Application Form

Yes, I would like to APPLY to work with Dr. Jean Duane to help me understand cultural constraints that impede my ability to gracefully live with food sensitivities. I’ll learn how to develop empowering strategies and day-to-day practices to live the fulfilling life I dream of.

First Name*

Last Name*

Address*

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Phone*

Email*

In order to ensure that working with Dr. Duane is a good fit for your needs, please take a moment to answer the following questions. Thank you.

What foods are you sensitive to?

What aspects of your food-sensitive lifestyle do you feel you need help with?

Are other people in your household following the same diet as you? Do you feel safe in your home environment? If not, please describe your situation.

Do you need help developing strategies to improve your food-centered social experiences?

Do you need help developing menus, converting recipes, and figuring out what is safe for you to eat?

What medical diagnostic tests have you had to determine your food sensitivities?

Our Terms

Subject: Discussion Group, Workshop, or Mentoring Facilitator: Dr. Jean Elizabeth Duane

Discussion Site: Virtual Discussion Application (such as Zoom or phone)

Purpose
You will be participating in a virtual (Zoom or a similar type application) discussion group, workshop, or one-on-one mentoring sessions. The purpose of these discussions is for participants to share scenarios, set goals, and to understand more about the relational aspects of adults who have gluten sensitivities.

Procedures
As a participant, you may be invited to ask and answer questions, may volunteer to contribute stories and opinions, and may contribute help other participants develop strategies to navigate social conundrums. You understand that the discussion will be recorded and may be used in research conducted by Dr. Jean Duane. If used, your name will be replaced with a pseudonym.

Participation
Participating in this discussion is completely voluntary. Even if you decide to participate now, you may change your mind and stop at any time. You may choose not to continue with the discussion by closing the session, for any reason without penalty or other benefits to which you are entitled.

Risks or Discomforts
Potential risks and/or discomforts of participation may include minor emotional distress while contemplating the struggles associated with living with dietary restrictions.

Benefits
Possible benefits of participation include providing insight for adults who live the gluten free lifestyle by supplying information on how others cope. Further, the on-going research conducted by Dr. Duane will afford caregivers, cooks, and others a path to empathy by creating an awareness of the plight of everyday life for those with severe food sensitivities.

Consideration to Participate
You may be charged a participation fee. This fee is non-refundable.

Confidentiality
Audio and video recordings of the discussion groups will be preserved. Audio portions (protecting visual identities of discussion participants) may be used in a variety of ways including, but not limited to, quotations of participants used in research studies and audios used in an audio-montage. Identity of individuals participating in studies will not be disclosed when information is presented or published. However, should any information contained in the discussions be the subject of a court order or lawful subpoena, Alternative Cook, LLC might not be able to avoid compliance with the order or subpoena. The research information may be shared with federal agencies or local committees who are responsible for protecting research participants, including individuals on behalf of celiac.com.

Participant Eligibility
Before you begin, please note that the data you provide may be collected and used by Alternative Cook, LLC. This research is only for US residents over the age of 18 (or 19 in Nebraska). Please be mindful to use a secured Internet connection for your privacy. Your confidentiality will be maintained to the degree permitted by the technology used. Specifically, no guarantees can be made regarding the interception of data sent via the Internet by any third parties.

Questions
If you have any questions please feel free to contact Dr. Jean Duane at drjeanduane@gmail.com.

Checking the “I concur” box indicates that I have read and understand the Consent Form and agree to be audio and video recorded.
I concur You must agree to our terms in order to submit this form.

Dr. Duane will review your application and email you within 48 hours. Please do not be disappointed if you are not selected, as I can only work with a small number of devoted people at a time.