JAS Client Consent Form

Full Name *

Date *

Date of Birth *

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

Yes

No

Tick the boxes below if you agree.

I agree that

JAS can speak to the organisations listed below and share any information that might help me with my legal matters.

The organisations listed below can provide JAS with confidential, personal and health information they hold about me, including and assessments or reports that I have had done.

My lawyer or Legal Service

NDIA

My support services

NSW Health

Department of Education

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 *

Tick the boxes below if you agree.

Contacts

Legals

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