Free Consent to Treatment - Maryland

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, consent to treatment at

, agree to receive treatment and do voluntarily or an alternative

treatment program arranged by the Department of Health and Mental Hygiene. 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 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; agency; and the Division of Parole and Probation. The terms of this document have been fully explained to me, and I have been given the opportunity to ask questions.
County

; pretrial

Date

Signature of Defendant

Signature of Defense Attorney

Reset
CC-DC/CR 109 (Rev. 10/2004)