Approved, SCAO STATE OF MICHIGAN CASE NO. WAIVER OF PRIVILEGE JUDICIAL DISTRICT AGAINST DISCLOSURE (Alcohol/Substance Abuse Treatment) Court address Court telephone no. Defendant name and address The State of Michigan THE PEOPLE OF v Program name: Director or designee: Release to: District Court I, the defendant in this case, waive my privilege against disclosure regarding alcohol/substsance abuse treatment and authorize theabove program, its director or designee to release any and all information and records concerning my attendance, progress, servicesreceived, counseling reports, conduct appraisals, and recommendations for additional services to the district court listed above forthe purpose of assisting the court in an appropriate disposition of this case. This authorization will remain in effect until the purpose for which it was given no longer exists. Date Defendants signature Witness DC 214 (11/83) WAIVER OF PRIVILEGE AGAINST DISCLOSURE (Alcohol/Substance Abuse Treatment)