ATTACHMENT_2_-_14-R-0011_-_2.pdf

ATTACHMENT 2 CSOSA-14-R-0011

Court Services and Offender Supervision Agency for the District of Columbia

COMMUNITY SUPERVISION SERVICES

CONSENT FOR THE RELEASE OF SENSITIVE OFFENDER INFORMATION:

MENTAL HEALTH TREATMENT

OR

SEX OFFENDER TREATMENT

I, ___________________________________________, hereby consent to the release of the following information, (Name of offender)

(nature of information to be disclosed) by the Court Services and Offender Supervision Agency (CSOSA) to ____________________________________.

(authorized person or organization recipient)

In authorizing this disclosure of mental health information, I understand that the information will be used for the purpose of monitoring my compliance with sex offender treatment and supervision, both now and in the future. I understand that I may permit CSOSA to release information that it obtains after the date of this authorization for a period of up to 365 calendar days. If I do not state below when this authorization expires, then it will expire 365 calendar days from the date that I signed this form. I understand that this information cannot be disclosed by the person or organization who receives it without my authorization and that the law requires this notice:

The unauthorized disclosure of mental health information violates the provisions of the District of Columbia Mental Health Information Act of 1978 (D.C. Official Code §§ 7-1201.01 – 7- 1208.07). Disclosures may only be made pursuant to a valid authorization by the client or as provided in Titles III or IV that Act. The Act provides for civil damages and criminal penalties for violations.

I understand that this consent may be revoked in writing by me except in connection with a life or health insurance policy under D.C. Official Code § 7-1202.02(a)(3). I also understand that I have a right to examine and review my mental health records. I understand that a copy of this waiver will be provided to me as well as the individual responsible for making the actual disclosure(s). I also understand that a copy of this waiver will be placed in my file.

Authorization for release of information expires on __________(date cannot exceed 365 calendar days from the date this form is signed).

Signature of Offender/Date Signed Witnessed By/Date Signed Offender’s Date of Birth Offender's DCDC Number Offender ‘s PDID Number