Consent for the Release of Confidential Information: Mental Health Court Referral The purpose of this consent form is to allow the disclosure of information among the agencies listed below. This information includes any and all Mental Health, Substance Abuse, Psychological, or Medical Treatment including HIV or other records and information concerning my admission, diagnosis, psychological history, treatment, and discharge, unless limited below. All information may be communicated verbally and or in writing. I, ______________________________________________ , hereby consent to communication among the (Name of Defendant) following parties checked below. My date of birth is ____________, Case Number is _________________. ____ ____ ____ ____ ____ ____ ____ Riverside County Public Defender’s Office Defense Attorney ___________________________________________________________ Riverside County Department of Mental Health Superior Court of California, Riverside County Riverside County Probation Department __________________________________________________________________________ __________________________________________________________________________ ____ __________________________________________________________________________ (Other Agency/ies) (Communication with Family Member listed above) A limited release is authorized to provide my Psychiatric Diagnosis, Treatment Recommendations, Probation Terms, Progress in Treatment and _____________________________________ to the Riverside County District Attorney. I understand that this consent will remain in effect and cannot be revoked by me until: ____ there has been a formal and effective termination or revocation of Probation, Parole or other proceedings under which I was mandated to treatment, or (Specify other time when consent can be revoked and/or expired) I further understand that any disclosure made is bound by Title 42 of the Code of Federal Regulations governing confidentiality of Alcohol and Drug Abuse, and of Mental Health patient records, and the recipients of this information may disclose it only in connection with their official duties Date: _________________________ ______________________________________________________ (Signature of defendant/participant) ______________________________________________________ (Signature of parent, guardian, or authorized representative, if required) American LegalNet, Inc. www.FormsWorkFlow.com