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ACKNOWLEDGEMENT OF THE

RECEIPT OF DOCUMENTS RELATED TO ENROLLMENT IN

THE MONTGOMERY COUNTY ADULT DRUG 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 Montgomery County Adult Drug Court Program:

(Please Check)

Drug Court Agreement

Notice of Right to Confidentiality for Drug Court Participants

Consent for Disclosure of Confidential Alcohol and Drug Abuse Treatment and Related Medical

Information

Drug Court Participant Handbook

Probation/Supervision Order

ACKNOWLEDGED:

Participant’s Signature

Participant’s PRINTED name

Date

DRUG COURT AGREEMENT FOR RE-ADMISSION

I, , understand that I am voluntarily agreeing to participate in Montgomery County

Adult Drug Court as a special condition of my probation in criminal case number(s): .

In addition to complying with the conditions outlined in my probation contract, I am also required to comply

with the following terms:

1. I understand that because I am being re-admitted into Drug Court on a Motion for Reconsideration,

the Menu of Sanctions listed in the Drug Court Participant Handbook no longer applies to me. If I fail

to comply with any of the expectations listed below, I am subject to termination.

2. I have received a copy of the Drug Court Participant Handbook. I understand that it is my responsibility

to review this handbook.

3. I will comply with the expectations and requirements of Drug Court outlined by my case manager.

I can review these requirements in the Drug Court Participant Handbook.

4. I understand that completion of Drug Court takes a minimum of 20 months. My actual length of stay in

the program will be determined by the Drug Court team based on my compliance with program

requirements and progress toward the goals outlined in my treatment plan.

5. I will attend and participate in substance abuse treatment as directed by the Court.

I understand that substance abuse treatment may involve the use of medication to assist with cravings

and decrease the likelihood of relapse. If it is determined that I am an appropriate candidate for

medications including, but not limited to, Antabuse, Vivitrol, and Naltrexone, I must comply with

taking these medications.

6. I agree to attend a minimum of three (3) recovery meetings per week for every week that I am in Drug

Court unless incarceration or inpatient treatment prevents me from doing so.

7. I will be on time for all substance abuse treatment groups, appointments, and court appearances.

Failure to appear for any of these obligations could lead to the issuance of a bench warrant.

8. I understand that Drug Court imposes graduated sanctions for lack of compliance with program

requirements, including incarceration. I have the right to request and have a formal adversarial hearing

before the imposition of a sanction of incarceration or before being terminated from Drug Court.

9. 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 agree that I will not use or possess alcohol or marijuana or any other substance that will compromise

my sobriety. I understand that using or possessing any of these substances will result in a violation of

the terms of my probation.

I understand that I can be asked to report for drug and alcohol testing at any time while I am a Drug

Court participant and that my failure to report will result in a sanction by the Court.

I understand that using or possessing any substances that are not prescribed to me by my physician

must be approved by the Drug Court team. I understand that using or possessing substances that are

not approved by the team is a violation of Drug Court rules.

I understand that using or possessing any substances that may not be controlled dangerous

substances or otherwise illegal, but still provide a mood altering or hallucinogenic effect, will violate

the rules of Drug Court.

I will report for drug and alcohol testing as directed by my substance abuse treatment provider, case

manager, probation agent, Oxford House, or PRRS staff.

I also understand that any attempt to falsify a drug and alcohol test, including dilution, is grounds for

termination from Drug Court.

10.

I understand that I can be asked to wear the Secure Continuous Remote Alcohol Monitor (SCRAM)

bracelet at any time during my participation in Drug Court and agree to do so.

11.

I understand that I have 24 hours upon request to sign any releases of information not covered by the

Drug Court Agreement to allow my case manager and therapist access to medical and psychological

information needed to assess my status or determine treatment or service needs.

12.

I understand that I must get permission from my case manager and/or therapist prior to taking any

medication. Documentation of any prescribed

medications must be provided to my case manager

and therapist within 24 hours of receipt.

13. I understand that I am to reside in court approved sober housing within Montgomery County.

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.

14. I will obey all laws and be of good conduct. I will advise my case manager of any contact with law

enforcement, including traffic stops, even if I am not arrested or charged or do not receive a citation.

I understand that being charged with any incarcerable offense, including incarcerable traffic citations,

while in Drug Court could lead to me being held without bond pending the outcome of the new charge.

I understand that being convicted of a new crime while in Drug Court could lead to termination from

the program and revocation of my probation.

15. I understand that if I fail to complete Drug Court, the court will terminate me from the program and

sentence me in accordance with the law.

Defendant’s Name (Please Print)

Defendant’s Signature Date

Signature of Attorney for the Defendant Date

Notice of Right to Confidentiality for Drug 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 Drug Court Program, you are being provided with this Notice of Right to Confidentiality

for Drug 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 Montgomery County Adult Drug

Court, I am consenting to ongoing verbal and written communication about my compliance status among the

following individuals and agency staff involved with the Adult Drug 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 College personnel engaged with Drug Court participants

Montgomery County Circuit Court staff directly involved with the Adult Drug Court program

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 Drug 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 Drug Court Program in

accordance with the Drug 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 Drug 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 Drug 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.

I also understand that my case manager and therapist must have access to all medical and

psychological records while I am enrolled in the Montgomery County Adult Drug Court. By signing

this agreement, I am consenting to the release of these records to my case manager and therapist.

In addition to the individuals and agencies listed above, I am voluntarily authorizing my Drug 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

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 Montgomery County Adult Drug Court for the

case(s) listed above such as the discontinuation of all court-ordered supervision or probation upon my

successful completion of the drug court requirements, or upon sentencing for violating the terms of my drug

court involvement.

Signature of Program Participant Date

Signature of Witness Date

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