COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. : JUDICIAL SUBPOENA MALHEUR COUNTY CIRCUIT COURT Plaintiff(s) -against- S.A.F.E. COURT PROGRAM : Malheur County Courthouse 251 B Street West - Vale, OR: 97918 541/473-5533 : Defendant(s) : . . . . . . . . . . . .CONSENT .FOR .DISCLOSURE . . . . CONFIDENTIAL SUBSTANCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . OF . . . . . . . . ABUSE INFORMATION: S.A.F.E. Court REFERRAL THE PEOPLE OF THE STATE OF NEW YORK I, ______________________________________, hereby consent to communication between Lifeways Behavioral Health, Circuit Court Judges, Malheur County District Attorney, TO Defense Attorney, Malheur County Community Corrections, Training and Employment Consortium, the participant’s employers (present and future), the Department of Human Services, Malheur County Justice Courts, and the S.A.F.E. Court Coordinator. GREETINGS: The purpose of and need for this disclosure is to inform the court and other above-named WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before parties of my treatment services and my , the Honorable eligibility and/or acceptability for substance abuseCourt at the treatment attendance, prognosis, compliance, and progress in accordance with the S.A.F.E. Court located at County of inmonitoring criteria. the room , on day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the Disclosure of this confidential information may be made only as necessary for and pertinent to hearings and/or reports concerning charges and case numbers. Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to I understand that this consent will remain in effect and cannot be revoked by me until the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a there has been a formal and effective termination of my involvement with the S.A.F.E. Court for result of your failure to comply. the case named above, such as the discontinuation of all court and/or probation supervision upon my successful completion of the S.A.F.E. Court requirements or upon one of the Justices of the Witness, Honorable , sentencing for violating the terms of my S.A.F.E. Court involvement and/or20 probation. Court in County, day of , 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 patient (or client) (Attorney must sign above and type name below) records, and that recipients of this information may re-disclose it only in connection with their official duties. Attorney(s) 20_____. Dated ________ day of _____________________________,for Office and P.O. Address ___________________________________ Defendant Telephone No.: Facsimile No.: Consent for Disclosure of Confidential Substance Abuse Information: S.A.F.E. Court Referral (7/25/2002) E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com