Consent To Treatment {CC-DC-CR 109}

CIRCUIT COURT DISTRICT COURT OF MARYLAND FORLocated atCase No.Court AddressCity/CountySTATE OF MARYLANDvs.DefendantD.O.B.AddressCity, State, ZipTelephoneCC-DC-CR-109 (Rev. 12/2018)CONSENT TO TREATMENT I,, agree to receive treatment and dovoluntarily consent to treatment at . I further agree to enter and complete any residential or out-patient program recommended andarranged by the Maryland Department of Health and to comply with the terms of any Probation Order inthis case and any after-care plan developed for me. I have been informed that if I fail to comply with theconditions of my probation, I will face imposition of the sentence which was suspended. The terms of this document have been fully explained to me, and I have been given theopportunity to ask questions.DateSignature of DefendantSignature of Defense Attorneyand counseling to the District Court of Maryland or the Circuit Court for;the Maryland Department of Health; pretrial agency; and theDivision of Parole and Probation; and . I further agree to complete a Consent to Disclose Protected Health Information form(CC-DC-CR-110) to enable the release of any and all information pertaining to my evaluation, treatment, CPF ID No. American LegalNet, Inc. www.FormsWorkFlow.com