Wellness Consent Form

OMB No. 0930-0196

Expiration Date: 09/30/2019

Attachment C

Wellness Focus Group Authorization and Release

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid Office Management and Budget (OMB) control number. The OMB control number for this project is 0930-0196. The public reporting burden for this collection of information is estimated to average 90 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Substance Abuse and Mental Health Services Administration (SAMHSA) Reports Clearance Officer, 5600 Fishers Lane, Room 15E57-B, Rockville, Maryland 20857.

Center for Mental Health Services

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, Substance Abuse and Mental Health Services Administration (SAMHSA) to use the information, feedback, and opinions I provided through a focus group on the development and editing of Wellness materials aimed toward the general public and people in recovery from mental and/or substance use disorders.

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Full Name of Adult

_____________________________ _________________________________

Signature of Adult Date

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Address

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Phone Number Date

SAMHSA’s Wellness Initiative raises awareness of health disparities between people with serious mental and/or substance use disorders and the general population. Research indicates that there are alarming health disparities between people with serious mental and/or substance use disorders and the general population. Individuals with behavioral health conditions are likely to die decades earlier, mostly owing to preventable, chronic medical conditions. Many people who have experienced these disorders can achieve a full and satisfying life in the community, especially when they can access effective services and support systems. The Wellness Initiative encourages people to improve their mental and physical health through positive lifestyle changes. Wellness can improve quality of life and increase years of life, especially for people with behavioral health conditions.

Visit www.samhsa.gov/wellness-initiative for more information.

Attachment C—Wellness Focus Group Authorization and Release