Free (dc214.pdf) - Michigan

Approved, SCAO

STATE OF MICHIGAN JUDICIAL DISTRICT

WAIVER OF PRIVILEGE AGAINST DISCLOSURE (Alcohol/Substance Abuse Treatment)

CASE NO.

Court

address

Court telephone no.

The State of Michigan THE PEOPLE OF v

Defendant name and address

Program name: Director or designee: Release to: District Court

I, the defendant in this case, waive my privilege against disclosure regarding alcohol/substsance abuse treatment and authorize the above program, its director or designee to release any and all information and records concerning my attendance, progress, services received, counseling reports, conduct appraisals, and recommendations for additional services to the district court listed above for the purpose of assisting the court in an appropriate disposition of this case.

This authorization will remain in effect until the purpose for which it was given no longer exists.

Date

Defendant's signature

Witness

DC 214 (11/83)

WAIVER OF PRIVILEGE AGAINST DISCLOSURE (Alcohol/Substance Abuse Treatment)