King County District Court Regional Mental Health Court Agreement / Conditions of Treatment Defendant's Name: Cause Number(s): Cause Number(s): Cause Number(s): Current Mental Health Treatment Provider: Current Case Manager: Charge(s): Charge(s): Charge(s): Date of Birth: DEFENDANT SHALL (please initial the conditions imposed by the Court): Comply with mental health treatment and chemical dependency treatment as approved by the judge or probation and attend all recommended individual and group appointments. ____ ____ ____ ____ ____ ____ ____ ____ ________ Take all medications as recommended by a prescriber approved by the judge or probation. Obtain a chemical dependency assessment with a provider approved by the judge or probation within _____ days if directed to do so by the judge or probation. Follow all treatment recommendations. Complete a certified Domestic Violence Treatment program with a provider approved by the judge or probation if directed to do so by the judge or probation. Do not change mental health, chemical dependency, or domestic violence treatment providers without advance approval from the judge or probation. Sign all releases of information as requested by probation to monitor compliance with these Conditions of Treatment and other conditions as ordered by Mental Health Court. Comply with all rules and regulations of your residence. Do not change your residence without advance approval from the judge or probation. Current Phone: Current Address: Do not use alcohol or any non-prescribed controlled drugs, marijuana/medical marijuana, or synthetic drugs such as spice. Submit to random drug and alcohol testing when directed to do so. Do not harm or threaten to harm yourself, others, or another's property Do not possess, own, or have under your control any firearm or weapon. Do not commit any new law violations. Meet with probation _____times per month. This may be increased or decreased based upon need and compliance with the treatment plan. Attend regular review hearings with the court as scheduled. Obtain permission from the judge prior to travel if travel occurs out of state or if travel interferes with the conditions of treatment, probation, or the court. Comply with: Daily medication monitoring as scheduled by your mental health provider and/or probation; DBT as scheduled by your provider; MRT as scheduled by your provider or by CCAP. Other: ____ ____ ____ ____ ______ ______ ______ Signature of Defendant: _____________________________________ ______________________________________________________ Date: _____________________ RMHC agreement conditions of treatment 3.21.16.doc - KCDC Apr 2016 American LegalNet, Inc. www.FormsWorkFlow.com