Attachment J-5 Release of Information-Substance Abuse Treatment.pdf
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- Attached to
- Supportive Housing Services (Up to 180 Days)
- Solicitation number
- 9594CS26Q0075
About this file
This is a consent form template for the release of substance abuse treatment information used by the Court Services and Offender Supervision Agency for the District of Columbia.
The form permits offenders under CSOSA supervision to authorize the disclosure of their substance abuse treatment records through one of two consent mechanisms. The Criminal Justice Consent option allows disclosure of treatment information to criminal justice entities including the presiding judge, prosecutor, defense attorney, and CSOSA Community Supervision Services handling the offender's case. Information disclosed under this consent is limited to diagnosis, attendance or non-attendance at treatment sessions, cooperation with the treatment program, and prognosis. This consent remains effective and irrevocable until the offender's involvement in the criminal justice system ends. The General Consent option permits disclosure to other authorized persons or organizations for purposes such as informing parties of the offender's participation in drug and/or alcohol treatment as a condition of community release or demonstrating efforts to remain clean and sober. General Consent may be revoked by the offender at any time except regarding disclosures already made, and expires on a date or upon an event specified by the offender. All disclosures made under either consent type are governed by Title 42, Code of Federal Regulations, Part 2, which protects the confidentiality of alcohol and drug abuse patient records and prohibits redisclosure without express written consent. The form requires signature of the offender and a witness, along with date signatures from both parties.
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Court Services and Offender Supervision Agency for the District of Columbia
CSOSA – Substance Abuse Treatment Revised 8/2008
Attachment J-5: 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: __________
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