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Consent To Treatment CC-DC-CR 109 - Maryland
| Consent To Treatment Form. This is a Maryland form and can be used in Criminal District Court Statewide . |
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CIRCUIT COURT DISTRICT COURT OF MARYLAND FOR City/County Located at STATE OF MARYLAND Court Address Case No. D.O.B. vs. Defendant Address City, State, Zip Telephone CONSENT TO TREATMENT I, consent to treatment at , agree to receive treatment and do voluntarily or an alternative treatment program arranged by the Department of Health and Mental Hygiene. I further agree to enter and complete any residential or out-patient program recommended and arranged by the Department of Health and Mental Hygiene and to comply with the terms of any Probation Order in this case and any after-care plan developed for me. I have been informed that if I fail to comply with the conditions of my probation, I will face imposition of the sentence which was suspended. I further agree to the release of any and all information pertaining to my evaluation, treatment, and counseling to the District Court of Maryland or the Circuit Court for the Department of Health and Mental Hygiene; agency; and the Division of Parole and Probation. The terms of this document have been fully explained to me, and I have been given the opportunity to ask questions. County ; pretrial Date Signature of Defendant Signature of Defense Attorney CC-DC/CR 109 (Rev. 10/2004) American LegalNet, Inc. www.FormsWorkFlow.com
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