Stanislaus — Therapy note release form

Source: https://www.stanislaus.courts.ca.gov/system/files/forms-and-filings/therapy-note-release-form-3-10-25.pdf

PARTY WITHOUT ATTORNEY OR ATTORNEY STATE BAR NO: NAME: FOR COURT USE ONLY

FIRM NAME:

ADDRESS:

EMAIL ADDRESS:

ATTORNEY FOR: SUPERIOR COURT OF CALIFORNIA, COUNTY OF STANISLAUS Street Address: 800 11th Street, Modesto, CA 95354 Civil Clerk’s Office: 1100 I Street, P.O. Box 1098, Modesto, CA 95353 CASE NAME:

CASE NUMBER

RELEASE OF THERAPEUTIC TREATMENT NOTES FOR LITIGATION PURPOSES

Mental Health Professional Name:__________________________________ Reason for Access and Intended Use:________________________________

Hearing Date, Time and Department:________________________________

I _____________________[party/attorney] understand that any court records of therapeutic treatment notes released to me are private and confidential by law and I agree to only use any such court records for the stated reasons and intended purposes identified herein.

I further agree to maintain the privacy and confidentiality of the court records released to me and not to copy, publish, disseminate or deliver either the records themselves or the information contained within them except pursuant to further Court order.

I understand that the terms of this Local Form are equivalent to a Court order and that violation of the terms may result in monetary, issue, or evidentiary sanctions, up to and including contempt of court, after notice and an opportunity to be heard regarding the violations.

Nothing in this Local Form shall be construed as limiting the Court’s discretion with respect to the admission, review and consideration of the records, nor as limiting any party or attorney’s rights to conduct discovery, proffer evidence, or request to have documentary evidence sealed and/or the courtroom closed pursuant to the state Rules of Court.

I declare under penalty of perjury under the laws of the State of California that the preceding statements are true and correct to the best of my personal knowledge, information and belief, and that this Local Form was executed by the undersigned as indicated below.

Date: Place:

Signature:_______________________________________

FL022 (Mandatory Form) Eff.: 07/25