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BROWN COUNTY PROBATION DEPT. PO BOX 85, NASHVILLE, IN 47448 PHONE (812) 988-5505 FAX (812) 988-5506 CRIMINAL JUSTICE CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION I, hereby consent to unrestricted communication between the BROWN COUNTY PROBATION DEPARTMENT, and 1.__BROWN CIRCUIT 4._BROWN COUNTY COMMUNITY CORRECTIONS 2.__BROWN COUNTY PROSECUTOR’S OFFICE CO. PROBATION DEPT. BROWN COUNTY The purpose of and need for the disclosure is to inform the agency(ies) or individuals listed above of my attendance and progress in treatment and on probation. The extent of necessary information to be disclosed includes: 1. Assessment/Diagnosis 6. Progress Notes 2. Attendance 7. Treatment plan 3. Prognosis 8. Discharge plan/Completion letter 4. Probation records 9. Results of Drug/Alcohol Screens 5. Probable Cause Affidavit 10. Employment records I understand that this consent will remain in effect and cannot be revoked by me until there has been a formal and effective termination or revocation of release from confinement, probation, community corrections, or other proceedings under which I was mandated into required services. In all cases, it will expire at the end of community corrections supervision, probation term, and/or probation revocation proceedings, whichever occurs last. In addition, I understand that certain non-identifying information pertaining to my participation and progress in Court ordered programs may be used for purposes of evaluation and/or audit of the programs. I also understand that any disclosure made between the above named agencies or individuals is bound by Part 2 of Title 42 of the Code of Federal Regulations governing confidentiality of alcohol and drug abuse patient records ant that recipients of this information may re-disclose it only in connection with their official duties. (Date) (Defendant/Patient Signature) (Witness Signature) (Defendant/Patient Address) (Parent/Guardian, if patient is under 18 (Social Security Number) (Case Number) or under guardianship) (A photocopy of this completed form shall be as valid as the original.)