CONSENT FOR DISCLOSURE OF CONFIDENTIAL SUBSTANCE ABUSE TREATMENT INFORMATION: FAMILY DRUG COURT REFFERAL I, ______________________, hereby consent to communication between Choices Unlimited, Step II, or NASAC and Judge Charles M. McGee, the Deputy District Attorney representing Washoe County Department of Social Services, the Deputy Attorney General representing the Division of Child and Family Services, my Deputy Public Defender or my defense counsel _____________________, the Department of Parole and Probation for the State of Nevada, Washoe County Department o f Social Services, the State of Nevada Division of Child and Family Services, Integrated Services, Court staff, CASA and the Foster Grandparent Program. The purpose and need for this disclosure is to inform the court and the other above-named parties of my eligibility and/or acceptability for substance abuse treatment services and my treatment attendance, prognosis, compliance, toxicology results, and progress in accordance with the Family Drug Court monitoring criteria. Disclosure of this confidential information may be made only as necessary for and pertinent to hearings and/or reports concerning: Case No. Case Name C harge _______________________________________________________________________ _____________________________________________________________________ I understand that this consent will remain in effect and cannot be revoked by me until there has been a formal and effective termination of my involvement with the Family Drug Court for the case(s) named above, such as the discontinuation of all court (and/or, where relevant, probation) supervision upon my successful completion of the drug court requirements or upon sentencing for violating the terms of my drug court involvement (and/or, where relevant, probation.) I understand that any disclosure made is bound by Part 2 of Title 42 of the Code of Federal Regulations, which governs the confidentiality of substance abuse client records, and that recipients of this information may re-disclose it only in connection with their official duties. Date___________________ Signature of Client_____________________________________