Sonoma — Agreement to Provide Mental Health Treatment

Source: https://sonoma.courts.ca.gov/system/files/forms-and-filings/mhd-agreement-provide-treatment-reports.pdf

Sonoma County Superior Court Mental Health Diversion Court Agreement to Provide Mental Health Treatment and Progress Reports

Name and Contact Information

Name of Patient

Name of Treatment Provider Title of Treatment Provider Agency of Treatment Provider Type of Care that will be Provided Address of Treatment Provider Phone Number of Treatment Provider

I understand that the patient referenced above will be participating in Mental Health Diversion (MHD) court. I also understand that in order to participate in MHD court, the patient will be required by the court to consent to the sharing of information, including but not limited to, medical and psychological records, progress reports, toxicology results and/or medication evaluation between the court, Sonoma County Behavioral Health, the probation department, and the patient’s third-party treatment providers. The patient has been advised that the patient’s records are protected under the Federal regulations governing Confidentiality of Medical, Alcohol and Drug Abuse Patient records, 42 CFR part 2, and cannot be disclosed without the patient’s written consent unless otherwise provided for in regulations. The patient has agreed to provide that consent and execute any further Releases of Information necessary regarding the reporting of the patient’s progress as a condition of MHD court. The patient also understands that the patient may revoke consent at any time except to the extent that action has been taken based on it, and that in any event, this consent expires automatically upon the court’s acknowledgement of successful completion and dismissal of criminal allegations or the court’s ruling of termination of MHD court.

I agree to provide treatment to this patient. I also agree to complete periodic progress reports to the court regarding the patient’s ongoing treatment during the course of MHD court (up to two years). A sample of the court’s universal progress report was attached to this form for my reference.

SIGN

Signed: _____________________________________________________________________________

Print Name and Title: _____________________________________________ Date: ______________

Forms MUST be emailed to MHDreports@sonomacourt.org Revised 11/27/24