Consent to Participate Mental Health Court Program (03/17/16) CCCR N106 A IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS THE PEOPLE OF THE STATE OF ILLINOIS v. ___________________________________________________ Defendant No._______________________________________ CONSENT TO PARTICIPATE MENTAL HEALTH COURT PROGRAM 1. I understand that I have no legal right to participate in the Mental Health Court Program. I have reviewed this Consent to Participate with my Attorney and I hereby knowingly and voluntarily execute this Consent to Participate which allows me to participate in the Mental Health Court Program. 2. I agree to participate in and cooperate with any and all treatment recommendations, including, but not exclusively, any mental health or substance abuse assessments and/or treatment recommended by the Mental Health Court Team, which consists of the Judge, Local PSC Coordinator, Prosecutor(s), Public Defender or Defense Counsel, Probation, Treatment Provider(s), Case Manager(s) and any other personnel designated by the Mental Health Court Team. 3. I understand that it is essential that all members of the Mental Health Court Team, including the Judge, communicate as a team and share information regarding my participation in the Mental Health Court, including compliance with treatment, and I agree to them doing so. Upon entry into the Mental Health Court, I consent to the Mental Health Court public defender representing me at Mental Health Court staffings and at Mental Health Court status review hearings unless I have privately retained counsel. I understand that my privately retained counsel will be required to represent me at all staffings and Mental Health Court status review hearings. In the event that my privately retained counsel is unable to attend staffings and/or court, I understand that my attorney will arrange for other counsel to appear on my behalf. 4. I agree to adhere to all components of my treatment, including attending all counseling sessions, treatment programs, taking my medication as prescribed, engaging in structured daily activities as recommended by the Mental Health Court Team, and cooperation with home visits by Mental Health Court Team members. 5. I agree to appear in court as required. I understand that my court hearings will be open to the public and an observer could connect my identity with the fact that I am in treatment and I consent to this type of disclosure to a third person. 6. I agree to reside in ________________________ County and to keep the Mental Health Court Team advised of my current address and telephone number, employment status, and any new arrests at all times while in the program. 7. I agree to sign any and all releases of information consenting to the disclosure of information to the Mental Health Court Team. I understand that if I refuse to comply with signing a release when requested, it may be grounds for my termination from Mental Health Court. 8. I agree to be truthful, cooperative, and respectful with the Mental Health Court Team. 9. I understand that based upon any report (written or oral) of my violation of this Consent to Participate, the Mental Health Court Judge may: authorize a warrant for my arrest; impose any sanction, including jail time if ordered by the Judge; adjust my treatment plan; or modify or revoke any conditions of my probation or bond. My violation(s) may result in proceedings being initiated seeking my termination from the Mental Health Court and these proceedings could either be resolved in Mental Health Court or be referred back to traditional court. DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS Page 1 of 2 Consent to Participate Mental Health Court Program (03/17/16) CCCR N106 B 10. I understand that my alcohol, drug treatment and mental health records are protected by Part 2 of Title 42 of the Code of Federal Regulations (CFR) and HIPAA; Illinois Mental Health and Developmental Disabilities Confidentiality Act, 740 ILCS 110 et seq.; 45 C.F.R Parts 160 & 164. I understand that I may revoke this Consent To Participate at any time except to the extent that action has been taken in reliance on it. In any event, this Consent To Participate expires upon the termination of the probation I am serving in this case, or the termination of all proceedings with regard to this cause of action as named above. 11. I understand that I may voluntarily withdraw from the Mental Health Court Program in accordance with the Mental Health Court procedures. I understand that there may be consequences, actual or potential, which will result from my withdrawal. 12. I understand that at the discretion of the presiding Mental Health Court Judge, for purposes of research and/or education, other persons may be permitted to attend the Mental Health Court Team meetings where communications as to my case will occur. 13. I understand that language help is available and if I need assistance, it is my responsibility to inform the court I need help. I UNDERSTAND THAT THE MENTAL HEALTH COURT PROGRAM MAY BE AN OPPORTUNITY FOR ME TO AVOID CONVICTION, JAIL AND/OR PRISON AND TO HELP ME OBTAIN TREATMENT AND MOVE FORWARD WITH MY LIFE. I ALSO UNDERSTAND THAT ALL MEMBERS OF THE MENTAL HEALTH COURT TEAM WANT TO SEE ME SUCCEED AND ARE HERE TO HELP ME. ____________________________________________________ Date ____________________________________________________ Name(Print or Type) ____________________________________________________ Signature _____________________________ Signature of Interpreter (Where applicable) _____________________________ Signature of Parent or Guardian (Where applicable) I HAVE REVIEWED THIS CONSENT WITH THE DEFENDANT. THE DEFENDANT UNDERSTANDS IT AND VOLUNTARILY AGREES TO PARTICIPATE. I FURTHER UNDERSTAND THAT THE MENTAL HEALTH COURT TEAM WILL BE DISCUSSING THE DEFENDANT'S COMPLIANCE AND COOPERATION WITH HIS/HER TREATMENT PLAN AND TERMS OF SUPERVISION AT MENTAL HEALTH COURT STAFFINGS AND AT MENTAL HEALTH COURT STATUS REVIEW HEARINGS. I ACKNOWLEDGE THAT IF I REMAIN COUNSEL OF RECORD FOR THE DEFENDANT, I WILL APPEAR OR ARRANGE FOR OTHER COUNSEL TO APPEAR AT MENTAL HEALTH COURT TEAM STAFFINGS WHEN THE DEFENDANT IS SCHEDULED TO BE STAFFED BY THE MENTAL HEALTH COURT TEAM AND ALSO APPEAR AT OR ARRANGE FOR OTHER COUNSEL TO APPEAR WITH THE DEFENDANT AT ALL MENTAL HEALTH COURT HEARINGS. _______________________ Date _________________________________________ Signature of Defense Counsel/Public Defender ________