DJJ Form MHSA013 "Youth Consent for Release of Substance Abuse Treatment Records - Sample" - Florida

Form MHSA013 or the "Youth Consent For Release Of Substance Abuse Treatment Records - Sample" is a form issued by the Florida Department of Juvenile Justice.

The form was last revised in August 1, 2006 and is available for digital filing. Download an up-to-date Form MHSA013 in PDF-format down below or look it up on the Florida Department of Juvenile Justice Forms website.

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Download DJJ Form MHSA013 "Youth Consent for Release of Substance Abuse Treatment Records - Sample" - Florida

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SAMPLE
FLORIDA DEPARTMENT OF JUVENILE JUSTICE
Youth’s Name _______________________________
Date of Birth_____________________________
JJIS Number_____________________________
YOUTH CONSENT FOR RELEASE OF
SUBSTANCE ABUSE TREATMENT RECORDS
I, _________________________________________ hereby consent to communication and
(Name of Client/Youth)
sharing of clinical records between _________________________________________
(Substance Abuse Service Provider)
and the Department of Juvenile Justice (DJJ) and _______________________________
(DJJ Facility/Program)
The purpose of and need for the disclosure is to inform the Department of Juvenile Justice
and the DJJ facility/program listed above of my progress in treatment. The information to be
disclosed are records which describe my diagnosis and the extent of my substance abuse or
dependence, information about my cooperation with the treatment program, prognosis and
expected duration of my treatment.
I understand that my substance abuse treatment records are protected by State and Federal
regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R.,
Part 2, and cannot be disclosed without my written consent unless otherwise provided for by
law. I also understand that I may revoke this consent at any time except to the extent that
action has been taken in reliance on it. I further understand that this consent will
automatically expire when I am no longer in the custody of the Department of Juvenile
Justice.
________________________________________
_______________________
(Signature of Client/Youth)
(Date)
__________________________________________
_______________________
(Signature of Designated DJJ Staff Member)
(Date)
__________________________________________
_______________________
(Witness Signature)
(Date)
Rule 63N-1
MHSA 013
August 2006
SAMPLE
FLORIDA DEPARTMENT OF JUVENILE JUSTICE
Youth’s Name _______________________________
Date of Birth_____________________________
JJIS Number_____________________________
YOUTH CONSENT FOR RELEASE OF
SUBSTANCE ABUSE TREATMENT RECORDS
I, _________________________________________ hereby consent to communication and
(Name of Client/Youth)
sharing of clinical records between _________________________________________
(Substance Abuse Service Provider)
and the Department of Juvenile Justice (DJJ) and _______________________________
(DJJ Facility/Program)
The purpose of and need for the disclosure is to inform the Department of Juvenile Justice
and the DJJ facility/program listed above of my progress in treatment. The information to be
disclosed are records which describe my diagnosis and the extent of my substance abuse or
dependence, information about my cooperation with the treatment program, prognosis and
expected duration of my treatment.
I understand that my substance abuse treatment records are protected by State and Federal
regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R.,
Part 2, and cannot be disclosed without my written consent unless otherwise provided for by
law. I also understand that I may revoke this consent at any time except to the extent that
action has been taken in reliance on it. I further understand that this consent will
automatically expire when I am no longer in the custody of the Department of Juvenile
Justice.
________________________________________
_______________________
(Signature of Client/Youth)
(Date)
__________________________________________
_______________________
(Signature of Designated DJJ Staff Member)
(Date)
__________________________________________
_______________________
(Witness Signature)
(Date)
Rule 63N-1
MHSA 013
August 2006
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