CONSENT FOR RELEASE OF INFORMATION JD-CR-92 Rev. 7-05 Gen. Stat. 17a-693, 17a-694 STATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.gov COURT ORDERED REFERRAL FOR EVALUATION CONSENT FOR RELEASE OF INFORMATION BY DEPARTMENT OF PUBLIC HEALTH AND ADDICTION SERVICES (DPHAS) STATE VS. DOCKET NO. I, , (DEFENDANT) hereby authorize the DPHAS court liaison to disclose the results of my evaluation for alcohol and drug dependence performed pursuant to C.G.S. §§ 17a-693 and 17a-694 to: the Superior Court which ordered the evaluation, the state's attorney prosecuting my case, Court Support Services Division Adult Probation and my attorney. I understand that an examination report ordered pursuant to these sections shall not be open to the public or subject to disclosure except as noted above. The purpose of the disclosure is to provide the court with information so that it may rule on my request for diversion to alcohol or drug abuse treatment. I understand that I may revoke this consent at any time except to the extent that action has already been taken in reliance on it, or, until there has been a formal effective termination or revocation of my release from confinement, or probation or other proceeding under which I was mandated into treatment (whichever is later), and, the release shall terminate automatically upon final disposition of the case, including any sentence or suspended prosecution. I also understand that any disclosure made 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. (DATE) (SIGNATURE OF DEFENDANT/PATIENT) (DATE) (SIGNATURE OF PARENT OR GUARDIAN, IF REQUIRED) American LegalNet, Inc. www.FormsWorkflow.com