NCCS General Release

NOBLE COUNTY PROBATION DEPARTMENT

Noble County Community Corrections Court Services

General Consent for Release of Confidential Information

(Name of client)*

(Cause Number)*

hereby consent to reciprocal communication between Noble County Court Services and and the following: (i.e. Family member, Friend, Pastor, Doctor, Employer, Etc.)

*1. Name*

Phone*

Name

Phone

The purpose and need for disclosure is to provide collaboration with the above entities regarding my attendance, progress, and attitude toward my evaluation and required treatment, education or both. The extent of necessary information to be disclosed includes:

2. Prognosis

3. Results of Drug / Alcohol Screen

4. Required Services

5. Completion

* 6.

Any other information you wish to have shared

I understand that I may revoke this consent at any time in writing, except where there has been action taken in reliance upon this release. Otherwise this consent will remain in effect until there has been a formal and effective termination of my involvement with the A & D Program for the above referenced case, such as the discontinuation of all court supervision upon my successful completion of all A & D Program requirements OR upon sentencing for violation of the terms of my A&D Program involvement.

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

(Client Date of Birth)*

Date

(Client Signature)*

(Date)*

Date

(Staff Witness)

To be signed by staff

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