JAS Client Consent Form

Full Name *

Date *

Date of Birth *

I agree for JAS to support me in my current legal matters *

Yes

No

I agree that JAS can speak to the following organistions to share any information they have that might help me with my legal matters, including any assessments or reports that I have had done:

My lawyer or Legal Service

NDIA

My support services

Justice Health

Corrective services (including Statewide Disability Services (SDS) or Community Corrections)

Other – eg family, please list:Other – eg family, please list:

I agree that information can be shared between JAS and other services to support me to achieve my goals.

I understand I am only agreeing to this while JAS is helping me with my current legal matters.

I understand that I can change my mind at any time and decide I don’t want JAS to support me and JAS will stop.

I do not want JAS to share any information or talk to the following people or services:

Excluded Services/People

I agree that information about my case can be given to researchers who are interested in JAS. I understand that my name will not be given and will stay private.

Signature *

Clear

Use finger or mouse to sign

I have explained the meaning of this form to the client and declare the record of their informed consent is accurate.

Name of person explaining this form *

Date *

JAS Client Consent Form

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