Attachment J-3 Release of Information- Substance Abuse Treatment.pdf

Court Services and Offender Supervision Agency for the District of Columbia

CSOSA – Substance Abuse Treatment Revised 8/2008

RELEASE OF INFORMATION:

Substance Abuse Treatment

Name of Offender: __________________ DCDC No.__________ PDID No.__________ Date of Birth: ________

I hereby consent to one of the following :

Criminal Justice Consent: I consent to the release of the information noted below by ___________ to the authorized person(s) or organization recipient(s) noted directly below.

I understand that the information noted directly below may be disclosed to the judge presiding in my supervision case, the prosecutor, defense attorney, and CSOSA Community Supervision Services handling my case in Docket _________. I understand that this information may also be disclosed in open court. This means there is a possibility that those in the courtroom may hear this information.

The purpose of and need for this Criminal Justice Consent is to inform the criminal justice entities listed above of my attendance and progress in treatment. The information to be disclosed is limited to my diagnosis, my attendance or lack of attendance at treatment sessions, and my cooperation with the treatment program and prognosis.

I understand that this Criminal Justice Consent will remain effective and cannot be revoked by me until my involvement in the criminal justice system ends in Docket ___________.

General Consent: I consent to the release of the information noted below to the authorized person(s) or organization recipient(s) noted in the box below.

I understand that the information noted below may be released to inform the party named of my participation in drug and/or alcohol treatment as a condition of my release to the community. I understand that my participation in a substance abuse treatment program will be shared with the party named to inform the party of my efforts to remain clean and sober or for the purpose noted below.

I understand that this General Consent can be revoked by me at any time except to the extent a disclosure was already made in reliance on it, but if not revoked, it will remain in effect until ______________________________ [provide date or event upon which this consent expires].

Information to be disclosed:

Authorized Person or Organization Recipient for General Consent:

Purpose of Disclosure:

I also understand that any disclosure made as a result of this authorization is bound by Title 42, Code of Federal Regulations, Part 2, which governs the confidentiality of alcohol and other drug abuse patient records, and that the information may not be redisclosed without my express written consent.

Signature of Offender: ______________________ Witnessed by: ______________________

Date Signed: __________ Date Signed: __________

Attachment J-3