Fillable ACKNOWLEDGEMENT OF THE RECEIPT OF DOCUMENTS RELATED TO (Montgomery County Maryland)

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ACKNOWLEDGEMENT OF THE RECEIPT OF DOCUMENTS RELATED TO (Montgomery County Maryland)

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ACKNOWLEDGEMENT OF THE
RECEIPT OF DOCUMENTS RELATED TO ENROLLMENT IN
THE MONTGOMERY COUNTY CIRCUIT COURT MENTAL HEALTH COURT
Participant’s Name:
Criminal Number:
As the Defendant in the above-captioned case, I hereby acknowledge that I have received the following
documents from the Circuit Court Mental Health Court:
(Please Check)
Circuit Court Mental Health Court Agreement
Notice of Right to Confidentiality for Circuit Court Mental Health Court Participants
Consent for Disclosure of Confidential Alcohol and Drug Abuse Treatment and Related Medical
Information
Circuit Court Mental Health Court Participant Handbook
Probation/Supervision Order
ACKNOWLEDGED:
Participant’s Signature
Participant’s PRINTED name
Date
Montgomery County Circuit Court
Mental Health Court Agreement
NAME: CASE NUMBER(S):
Defendant petitions for acceptance into Circuit Court Mental Health Court and agrees:
1. I agree to successfully participate in the diagnostic evaluation as ordered by the Court and to successfully
comply with the Care Plan to the satisfaction of the treatment provider, case manager, probation officer and Court.
2. I agree to comply with any prescribed medication regimen as directed by my physician.
3. I agree to sign an authorization for the release of any medical, treatment or social service records requested to
facilitate the Mental Health Court process. I realize that this condition is necessary to coordinate treatment and
any other needed services and to monitor compliance.
4. I understand that I must reside in court approved housing within Montgomery County and comply with all house
rules. My probation agent can ensure that I am complying with this requirement by conducting a home visit at any
time. I am not required to receive prior notice of the home visit.
5. I agree to keep the treatment provider, probation officer, case manager, and the Court advised of any issues or
changes regarding housing, employment and/or volunteer work, medication, and treatment. I will report changes
within twenty-four (24) hours.
I agree that I will not use, possess, or knowingly associate with any person who uses or possesses any controlled
substance or illegal drug including, but not limited to, cocaine (powder, base, or “crack”), opiates, heroin,
methadone, buprenorphine, methamphetamines, benzodiazepines, K2, MDMA, psilocybin, butane hash, or LSD.
I understand that I may be required to abstain from alcohol as indicated in my Care Plan.
I understand that I can be asked to report for drug and alcohol testing at any time while I am a Circuit Court Mental
Health Court participant and that my failure to report will result in a sanction by the Court.
I will report for drug and alcohol testing as directed by my substance abuse treatment provider, case manager,
probation agent, or PRRS staff.
6. I agree to report any and all new contact with law enforcement to the Court.
7. I understand that a failure to appear for a court date may result in an immediate bench warrant.
8. I agree that the Court may extend probation to allow me to successfully complete my requirements.
9. I agree that during my participation in Mental Health Court, the presiding Judge may impose sanctions and/or
order termination from Mental Health Court for non-compliance.
10. The Court may impose sanctions or terminate Mental Health Court participation. If the Court orders my
termination from Mental Health Court, I understand I could be remanded into custody pending sentencing or a
show cause hearing to revoke probation.
I have read and understand this petition and hereby knowingly and voluntarily give up the rights listed on
this petition, petition the Court for acceptance into Mental Health Court, and enter into this agreement.
Being duly sworn to tell the truth, I, the undersigned, do hereby swear that I am eligible to participate in
the Montgomery County Circuit Court Mental Health Court Program and I meet the eligibility requirements
listed in this agreement.
Participant’s Signature Date
Defense Counsel’s Signature Date
Notice of Right to Confidentiality for Circuit Court
Mental Health Court Participants
CONFIDENTIALITY OF ALCOHOL AND DRUG ABUSE PATIENT RECORDS
Notification Form from 42 C.F.R. § 2.22(d)
The confidentiality of alcohol and drug abuse patient records maintained by this program is protected by federal law and
regulations. Generally, the program may not say to a person outside the program that a patient attends the program, or
disclose any information identifying a patient as an alcohol or drug abuser, unless:
1. The patient consents in writing;
2. The disclosure is allowed by a court order; or
3. The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit,
or program evaluation.
Violation of the federal law and regulations by a program is a crime. Suspected violations may be reported to appropriate
authorities in accordance with federal regulations.
Federal law and regulations do not protect any information about a crime committed by a patient either at the program
or against any person who works for the program or about any threat to commit such a crime.
Federal laws and regulations do not protect any information about suspected child abuse or neglect from being reported
under state law to appropriate state or local authorities.
As a participant in the Circuit Court Mental Health Court, you are being provided with this Notice of Right to
Confidentiality for Mental Health Court Participants to advise you of your right to confidentiality and of
restrictions on the disclosure of confidential information. You may elect to waive your right to confidentiality as
defined above by signing the CONSENT FOR DISCLOSURE OF CONFIDENTIAL ALCOHOL AND DRUG ABUSE
TREATMENT AND RELATED MEDICAL INFORMATION, thereby giving the consent needed to allow the disclosure
of confidential information as provided in section (1) “The patient consents in writing” of this Notice.
(See 42 U.S.C. § 290dd-3 and 42 U.S.C. § 290ee-3 for federal laws and 42 C.F.R. Part 2 for federal regulations.)
CONSENT FOR DISCLOSURE OF CONFIDENTIAL ALCOHOL AND DRUG ABUSE TREATMENT AND RELATED
MEDICAL INFORMATION
I, , being the Defendant in case number(s) and having
agreed to enroll and participate, understand that by being admitted to the Circuit Court Mental Health Court,
I am consenting to ongoing verbal and written communication about my compliance status among the
following individuals and agency staff involved with the Circuit Court Mental Health Court Program:
PARTICIPANT INITIALS
Montgomery County Circuit Court, including judges and support staff
Montgomery County Department of Health and Human Services staff
Maryland Treatment Centers
Montgomery County State’s Attorney’s Office
Office of the Public Defender or private defense counsel
Maryland Department of Parole and Probation
Montgomery County Department of Correction and Rehabilitation
Montgomery County Circuit Court staff directly involved with the Circuit Court Mental Health Court
Montgomery’s Miracles, Inc. Board of Directors
Any referring, treating or support agencies involved in the delivery of client services
I have received and reviewed the attached Notice of Right to Confidentiality for Circuit Court
Mental Health Court Participants with my attorney. I understand that treatment information is confidential
under federal law and that I am consenting to its release as described in this document. I understand that any
disclosure made is bound by Part 2 of Title 42 of the Code of Federal Regulations and that it is a crime to
violate this confidentiality requirement unless I voluntarily consent to permit its disclosure. People who
receive this confidential information may re-disclose it only in connection with their official duties.
I understand that the above mentioned parties will discuss confidential information only as needed for the
purposes of:
reporting on and monitoring my treatment, attendance, prognosis, and compliance with the terms and
conditions of my probation;
discussing, commenting, and assessing on my status and progress as a participant in the Circuit Court Mental
Health Court in accordance with the Circuit Court Mental Health Court’s reporting and monitoring criteria; and
to ensure the appropriate delivery of services and support.
I understand that information about my medical status, mental health and/or drug treatment status,
my arrest history, my levels of compliance or non-compliance with the conditions of my Circuit Court Mental
Health Court participation (including the results of urinalysis or other drug screening tools) and other material
information will be discussed and shared among members of the Circuit Court Mental Health Court team.
I further understand that summary information about my compliance or non-compliance will be
discussed in open court, specifically, whether I have attended all meetings, treatment sessions, the results of
urinalysis or other testing as required, and the disclosure of my compliance or non-compliance with the terms
and conditions of my probation as defined by the Court.
In addition to the individuals and agencies listed above, I am voluntarily authorizing my Circuit Court
Mental Health Court case manager to communicate with the following person(s) regarding my program
compliance and status to the extent necessary to facilitate my compliance, wellbeing, and safety:
Name Relationship Phone Number
Name Relationship Phone Number
Name Relationship Phone Number
I understand that my 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 Circuit Court Mental Health Court for the case(s)
listed above such as the discontinuation of all court-ordered supervision or probation upon my successful
completion of the Circuit Court Mental Health Court requirements, or upon sentencing for violating the terms
of my Mental Health Court involvement.
Signature of Program Participant Date
Signature of Witness Date
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ACKNOWLEDGEMENT OF THE RECEIPT OF DOCUMENTS RELATED TO (Montgomery County Maryland)

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Completed 6 May 2021

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