Orange County 714-245-9910
Inland Empire 951-307-0707
Los Angeles 213-212-3500

Long Beach 562-203-3911
Bay Area 408-482-9679

a Form – Consent for the Release of Confidential Information

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Consent for the Release of Confidential Information

    I, hereby consent to communication between Diversified Monitoring Systems and your legal representation, Court, Probation, and/or other regarding the following information:

    • Documentation of my monitoring including Verification of Enrollment, Progress Reports, Violations, Non-Compliance, and Notice of Completion.

    • “Attendance as Directed” for treatment or counseling (group, individual, case management,vocational and literacy)

    • Progress in program

    • Testing as directed and results of tests.

    • Other

    The purpose of and need for the disclosure is to inform the criminal justice agencies not listed above of your enrollment, attendance, and progress. Please be aware that your monitoring information may be used for future educational and research purposes. Any disclosure made is bound by Part 2 of Title 42 of the Code of Federal Regulations governing confidentiality of alcohol and drug abuse patient records.

    Signature:

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