JAS Client Consent Form You can say YES. You can say NO. It is up to you.Ask questions if you do not understand or feel you want more information. 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 following organisations to share any information they have that might help me with my legal matters, including any assessments or reports that I have had done: 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: JAS share information 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 agree that information can be shared between JAS and other services to support me to achieve my goals. agree current legal matters I understand I am only agreeing to this while JAS is helping me with my current legal matters. Change my mind 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. Don’t share info I do not want JAS to share any information or talk to the following people or services: Excluded Services/People Case info 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. Client/Guardian or Person Responsible Signature * Clear Use finger or mouse to sign Declaration 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 * If you are human, leave this field blank. Submit Updated 19/4/24
