Jasper County Recovery Court Application Form (Page 3 of 4) in pdf

CONSENT FOR DISCLOSURE OF CONFIDENTIAL SUBSTANCE ABUSE TREATMENT

INFORMATION FOR TREATMENT COURT REFERRAL

I, ____________________________, BEING THE Defendant in Case Number ____________________, and having

agreed to enroll and participate in the Jasper County Adult Treatment Court Program, hereby consent to allow on-going

communications about my compliance status among the following parties or agencies and all team members involved in

the Treatment Court Program to include, but not limited to: The Judge of the Jasper County Circuit Court (and his/her

Judicial Designee), the Court Administrator, Court Services Officer, the employees engaged in the Treatment Court

operations of the Jasper County Circuit Court, the Prosecuting Attorney’s Office, the Office of the Public Defender or my

private counsel, the Office of Probation and Parole, the Juvenile Office, Children’s Division, court-contracted drug and

alcohol testing companies, court-contracted locator (GPS) companies, Ozark Center employees or contract providers,

Lafayette House employees or contract providers, ASCENT Recovery, House, Inc., Lazarus House, and/or other referring

or treating agencies involved in the direct delivery of services through the Jasper County Treatment Court Program.

I understand that the purpose of, and the need for this disclosure, is to inform the Court and the other above-named parties

or agencies of my eligibility and/or acceptability for substance abuse treatment services as well as to report on and

adequately monitor my treatment, attendance, prognosis, and compliance with the terms and conditions of my probation

and to discuss and assess my status as a participant in the Treatment Court Program and assess and comment on my

progress in accordance with the Treatment Court’s reporting and monitoring criteria.

I agree to permit disclosure of this confidential information only as necessary for, and pertinent to, hearings, and/or

reports concerning the status of my participation and compliance with the conditions of my probation as defined by the

Treatment Court. I understand that information about my medical status, mental health, and/or drug treatment status, my

arrest history, my levels of compliance or non-compliance with the conditions of my Treatment Court participation

(including the results of urinalysis or other drug screening tools), and other material information will be discussed and

shared among members of the Treatment Court team. I further understand that summary information about my

compliance or lack thereof will be discussed in open court, specifically, whether I have attended all meetings, treatment

sessions, and the results of urinalysis other drug/alcohol testing as required, and the disclosure of my compliance or

noncompliance with the terms and conditions of my probation as defined by the Court. There may be visitors in court that

may hear this information as well and I consent to their attendance in court and information they may hear.

I understand that treatment information normally is confidential under federal law. I understand that any disclosure made

is bound by Part 2 of Title 42 of the Code of Federal Regulations, which governs the confidentiality of substance abuse

patient (or client) records and that it is a crime to violate this confidentiality requirement unless I voluntarily consent to

permit its disclosure. Recipients of this information may re-disclose it only in connection with their official duties. I also

acknowledge receipt of the Notice of Rights of Confidentiality.

I understand that this consent will remain in effect and cannot be revoked by me until there has been a formal and

effective termination of my involvement with the Treatment Court for the case named above such as the discontinuation

of all court-ordered supervision or probation upon my successful completion of the Treatment Court requirements, or

upon sentencing for violating the terms of my Treatment Court involvement.

__________________________________________________ Date____________________________

SIGNATURE OF PROGRAM PARTICIPANT

___________________________________________________Date____________________________

SIGNATURE OF WITNESS

Jasper County Recovery Court Application Form Page 3