RELEASE OF INFORMATION FOR ADMISSION TO MENTAL HEALTH COURT
LIMITED RELEASE TO BE USED SOLELY TO DETERMINE ELIGIBILITY FOR MENTAL
DATE OF BIRTH:
SOCIAL SECURITY NUMBER:
1. The clinical team of the Mental Health Court of Montgomery County has my permission
to review and verbally discuss my mental health treatment.
2. My records obtained and information obtained from this release are to be kept by the
Health and Human Services Mental Health Court team and are to be used solely for the
purpose of determining eligibility for participation in mental health court.
3. If I am accepted into mental health court the records can be used by the mental health
court in determining and providing my treatment.
4. Any information obtained by this release may NOT be used against me by the State’s
Attorney or Court outside of the Mental Health Court.
5. This information is being shared solely to determine my eligibility into the mental health
6. This authorization will be terminated upon my not being accepted into mental health
court, or, if accepted, upon completion of mental health court.
I understand that this release is valid when I sign it, and that I can withdraw this release at
anytime, but that withdrawal of the release may affect my eligibility for mental health court.