Consent Form Consent Form

National Recovery Month

5600 Fishers Lane, Rockville, Maryland 20857

Phone 240-276-1660 Fax 240-276-1670

Authorization and Release

The undersigned hereby authorizes the U.S. Department of Health and Human Services (DHHS), Substance Abuse and Mental Health Services Administration (SAMHSA) to use the information, feedback, and opinions I provided through a focus group in the development and editing of concepts for Public Service Announcements (PSAs) and in their production and post-productions stages.

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Full Name of Adult

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Signature of Adult Date

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Address

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Phone Number

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Witness Date

Project Description: National Recovery Month (Recovery Month) National Recovery Month (Recovery Month) is a national observance that educates Americans on the fact that addiction treatment and mental health services can enable those with a mental and/or substance use disorder to live a healthy and rewarding life. The observance’s main focus is to laud the gains made by those in recovery from these conditions, just as we would those who are managing other health conditions such as hypertension, diabetes, asthma and heart disease. Recovery Month spreads the positive message that behavioral health is essential to overall health, that prevention works, treatment is effective and people can and do recover.

Visit www.recoverymonth.gov for more information.

Note: Be advised that these PSAs will be in the public domain and may be reproduced in their entirety or excerpt pieces in official agency future publications without further permission.

Attachment C – Consent Form