Form Prob 11e - Authorization To Release Confidential Information Substance Abuse And Mental Health Treatment Programs - U.s. Probation System

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O
PROB 11E
(Rev. 5/05)
UNITED STATES PROBATION SYSTEM
AUTHORIZATION TO RELEASE CONFIDENTIAL INFORMATION
SUBSTANCE ABUSE AND MENTAL HEALTH TREATMENT PROGRAMS
I,
, the undersigned,
(Name of Client)
hereby authorize
to release confidential
(Name of Program)
information in its records, possession, or knowledge of whatever nature may now exist or come to exist to the United
States Probation Office of the
District of
.
(Name of Court)
(State)
The confidential information to be released will include: date of entrance to program; attendance records;
urine testing results; type, frequency and effectiveness of therapy (including psychotherapy notes); general adjustment
to program rules; type and dosage of medication; response to treatment; test results (psychological, vocational, etc.);
psychotherapy notes; date of and reason for withdrawal from program; and prognosis.
The information which I now authorize for release is to be used in connection with the preparation of a court-
ordered report.
I understand that the probation office may use the information hereby obtained only in connection with its
official duties, including total or partial disclosure of such, to the District Court.
I understand that this authorization is valid until I have been sentenced and my sentence is final, at which time
this authorization to use or disclose this information expires. I understand that information used or disclosed pursuant
to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.
I understand that I have the right to revoke this authorization, in writing, at any time by sending such written
notification to the program’s privacy contact at:
(Name and Address of Program)
I understand that if I revoke this authorization to release confidential information, I will thereby revoke my
authorization to further disclosure of such information. I also understand that revoking this authorization before the
completion of the presentence investigation will be reported to the court.
(Signature of Parent or Guardian if Client is a Minor)
(Signature of Client)
(Date Signed)
(Date Signed)
(Name & Title of Witness)
(Date Signed)
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