Consent To Treatment {CC-DC-CR 109} | Pdf Fpdf Doc Docx | Maryland
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Consent To Treatment {CC-DC-CR 109} | Pdf Fpdf Doc Docx | Maryland

Consent To Treatment {CC-DC-CR 109}

This is a Maryland form that can be used for Criminal within Statewide, District Court.

Alternate TextLast updated: 4/13/2015

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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, voluntarily consent to treatment at , agree to receive treatment and do . 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 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, and counseling to the District Court of Maryland or the Circuit Court for the Department of Health and Mental Hygiene; and the Division of Parole and Probation; and The terms of this document have been fully explained to me, and I have been given the opportunity to ask questions. ; pretrial agency; . Date Signature of Defendant Signature of Defense Attorney CC-DC-CR-109 (Rev. 09/2014) American LegalNet, Inc. www.FormsWorkFlow.com

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