NCCS CJ Release

Criminal Justice Consent for Release of Confidential Information

Name*

First NameLast Name

Date of Birth*

Date

, hereby consent to reciprocal communication between Noble County Court Services, and representative of the Noble County Circuit and Superior Courts; representatives from the Noble County Prosecuting Attorney; representatives from Noble County Probation Department; representatives from Kendallville Police Department; representatives from Avilla PD; representatives from Ligonier PD; representatives from Noble County Sheriff's Department; the client's attorney of record; AND the following individuals / agencies:

(List referral agencies or persons including treatment agencies, supportive living programs, employment programs, education programs, etc)

1.*

Name of person/agency

2. *

Name of person/agency. N/A if none

3.*

Name of person/agency. N/A if none

4.*

Name of person/agency.N/A if none

The purpose of this disclosure and need for the disclosure is to inform the above-named parties of my eligibility and/or acceptability for substance abuse treatment services and my treatment attendance, prognosis, compliance, and progress in accordance with my individual service contract.

The extent of necessary information to be disclosed includes:

1. Assessment 4. Progress Notes

2. Attendance 5.Discharge/Completion

3.Results of Drug/Alcohol Screens 6. Treatment Plan/Service Contract

Other Information to be shared:*

N/A if none

Disclosure of this confidential information may be only made as necessary for, and pertinent to, hearings and reports concerning case number(s):

Cause Number(s):*

List all case numbers under which the participant is enrolled in the drug and alcohol program.

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 court for the above referenced case, such as the discontinuation of all court supervision upon my successful completion of all court requirements OR upon sentencing for violation of the terms of supervision.

I also understand that any disclosure made between the above-named agencies or individuals is bound by Part 2 of Title 42 of the Code of Federal Regulations governing confidentiality of alcohol and drug abuse patient records and that recipients of this information may redisclose it only in connection with their official duties. I have received a copy of this signed form.

Date*

Date

Participant signature*

Witness

Interpreter

A photocopy of this completed form shall be as valid as the original * All blank lines must be crossed out or filled in at the time of signing.

NOBLE COUNTY PROBATION DEPARTMENT