• Family Room Registration

    Family Room Registration

    Please use this form to register for the Family Room Group. The group is intended for you and a support person to attend. The group takes place on Wednesdays at 6:00PM once per month at each office.

  • Groups will be held:

    The first Wednesday of every month in Southside

    The second wednesday of every month in Wexford

    The third wednesday of every month in Monroeville

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  • Family Room Group is for clients and a support person to attend. 

  • Release of information Consent

    Consent & Authorization for the release of information

  • I         Consent for the release and authorization the disclosure and use of my protected health information by JADE Wellness Center, in accordance with federal and/or state law, whichever is more protective of the client's confidentiality, by written copies, facsimile or verbal communication to:

  • Format: (000) 000-0000.

  • I also understand:

    1. That regulation 164.508 ensures my right to treatment, payment or enrollment in a health program regardless of whether I sign this authorization, and that I may refuse to sign.
    2. That when either federal or state laws afford me more a stringent level of privacy protection than those regulated by 164.508, JADE Wellness Center will always abide by the more stringent law.
    3. JADE Wellness Center will only disclose my health information gathered through treatment by our internal healthcare clinicians, and will not re-disclose my PHI received from any other external healthcare provider.
    4. That although Federal Law (42 CFR Part 2) prohibits re-disclosure of your PHI, recipients of your information could potentially disregard these and other laws.
    5. That this authorization expires 30 days after discharge from treatment episode.
  • Clear
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  • I understand that I may revoke all or part of this authorization verbally or in writing.
    Please contact the office if you wish to revoke this consent.

    This Consent/Authorization complies with the Privacy Regulations contained within Federal Register Vol. 65, Part II, Part 164; SubPart E 164.508.


    PROHIBITION OF REDISCLOSURE: This information has been disclosed to you from records whose confidentiality is protected by Federal Law.  Federal regulations prohibit you from making any further disclosures of this information except with the specific written consent of the person to whom it pertains or as otherwise permitted by such regulations.  A general release of medical or other information is NOT sufficient for this purpose.

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