Order for Release of Mental Health Records STATE OF ILLINOIS COUNTY OF COOK (Rev. 4/08/05) CCJP 0662 4351 } ss: IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS DEPARTMENT OF JUVENILE JUSTICE AND CHILD PROTECTION CHILD PROTECTION DIVISION IN THE INTEREST OF: __________________________________________________ Minor(s) } No. ____________________________ ORDER FOR RELEASE OF MENTAL HEALTH RECORDS THIS MATTER COMING on to be heard before the Honorable _____________________________, the parties being present and/or represented by counsel, and the Court being fully advised in the premises, and pursuant to the Mental Health and Developmental Disabilities Confidentiality Act, 740 ILCS 110/4 (a) (5) and 110/10 (d); IT IS HEREBY ORDERED THAT: _______________________________________________________________ shall release to the Offices of the Cook County Public Guardian (2245 West Ogden Avenue, Chicago, IL 60612), the Cook County State's Attorney (2245 West Ogden Avenue, Chicago, IL 60612) and __________________________ _____________________________, certified and delegated copies of all records relating to _______________ _____________________________, (date of birth) ______/______/______, including but not limited to records of the psychiatric and/or psychological hospitalization, evaluation and/or treatment. ENTERED: Dated: ________________________, _________ Atty. No.: ________________ Name: ______________________________________ Atty. for: ______________________________________ Address: ______________________________________ City/State/Zip: ___________________________________ Telephone: ____________________________________ DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS Print This Form For your protection and privacy, please press the Clear This Form button after you have printed the form. __________________________________________ Judge Judge's No. Clear This Form