CRJ Consent to ROI

NYS OFFICE OF ADDICTION AND SUPPORT SERVICES
Patient's/Defendant's Full Name (Last, First M.I.)*
Date of Birth

MonthDayYear
Date
CRIMINAL JUSTICE CONSENT TO RELEASE INFORMATION
FACILITY*
I, the undersigned patient/defendant, hereby consent to communication between staff of this facility and the following Criminal Justice Agenc(ies)/Person(s)*
EXAMPLES: Sullivan County Probation Department, NYS DOCCS, specific named court(s), specific named attorney(s), etc.
The purpose of this disclosure and the need for this disclosure is to inform the above named Criminal Justice Agency(ies), or person(s) of my attendance at, progress in and attitude toward my evaluation and treatment.

The extent of information to be disclosed is my diagnosis, information about my attendance or lack of attendance at treatment sessions, my cooperation with the treatment program.
I understand that my participation in treatment is a condition of: (check all applicable):

the disposition of a criminal proceeding against memy release from confinementthe execution of a sentence imposed upon methe suspension of a sentence imposed upon meanother action (SPECIFY):
I understand that, unless otherwise specified, this consent will remain in effect and may not be revoked until there has been a formal and effective termination or revocation of my release from confinement and/or parole, probation, final disposition of a conditional release or other action under which I was mandated into treatment.

I also understand that any disclosure made is bound by Part 2 of Title 42 of the Code of Federal Regulations governing con- fidentiality of alcohol and drug abuse patient records and the recipients of this information may redisclose it only in connection with their official duties.
(Signature of Patient/Defendant)*

Clear
(Signature of Parent/Guardian, when required)

Clear
(Print Name of Patient/Defendant)*
(Print Name of Parent/Guardian)
(Date)*

MonthDayYear
Date
(Date)

MonthDayYear
Date
Should be Empty:

CRIMINAL JUSTICE CONSENT TO RELEASE INFORMATION