Form CCCR0106 "Consent to Participate Mental Health Court Program" - Cook County, Illinois

What Is Form CCCR0106?

This is a legal form that was released by the Circuit Court - Cook County, Illinois - a government authority operating within Illinois. The form may be used strictly within Cook County. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 2, 2021;
  • The latest edition provided by the Circuit Court - Cook County, Illinois;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form CCCR0106 by clicking the link below or browse more documents and templates provided by the Circuit Court - Cook County, Illinois.

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Download Form CCCR0106 "Consent to Participate Mental Health Court Program" - Cook County, Illinois

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Consent to Participate Mental Health Court Program
(02/02/21) CCCR 0106 A
IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS
THE PEOPLE OF THE STATE OF ILLINOIS
v.
Case No. _______________
Defendant
CONSENT TO PARTICIPATE MENTAL HEALTH COURT PROGRAM
1.
I understand that I have no legal right to participate in the Mental Health Court Program. I have reviewed
this Consent to Participate with my Attorney and I hereby knowingly and voluntarily execute this Consent to
Participate which allows me to participate in the Mental Health Court Program.
2. I agree to participate in and cooperate with any and all treatment recommendations, including, but not
exclusively, any mental health or substance abuse assessments and/or treatment recommended by the Mental
Health Court Team, which consists of the Judge, Local PSC Coordinator, Prosecutor(s), Public Defender or
Defense Counsel, Probation, Treatment Provider(s), Case Manager(s) and any other personnel designated by the
Mental Health Court Team.
3. I understand that it is essential that all members of the Mental Health Court Team, including the Judge,
communicate as a team and share information regarding my participation in the Mental Health Court, including
compliance with treatment, and I agree to them doing so. Upon entry into the Mental Health Court, I consent
to the Mental Health Court public defender representing me at Mental Health Court staffings and at Mental
Health Court status review hearings unless I have privately retained counsel. I understand that my privately
retained counsel will be required to represent me at all staffings and Mental Health Court status review hearings.
In the event that my privately retained counsel is unable to attend staffings and/or court, I understand that
my attorney will arrange for other counsel to appear on my behalf.
4. I agree to adhere to all components of my treatment, including attending all counseling sessions, treatment
programs, taking my medication as prescribed, engaging in structured daily activities as recommended by the
Mental Health Court Team, and cooperation with home visits by Mental Health Court Team members.
5. I agree to remain drug and alcohol free (except for approved prescribed medications) and to submit to random
drug testing at the discretion of the Mental Health Court Team or any treatment provider and agree to the
disclosure of the results to the Mental Health Court Team. I understand that I may be sanctioned for providing
diluted, adulterated or substituted test specimens.
6. I agree to appear in court as required. I understand that my court hearings will be open to the public and an
observer could connect my identity with the fact that I am in treatment and I consent to this type of disclosure
to a third person.
7. I agree to reside in ________________________ County and to keep the Mental Health Court Team advised
of my current address and telephone number, employment status, and any new arrests at all times while in the
program.
8. I agree to sign any and all releases of information consenting to the disclosure of information to the Mental
Health Court Team. I understand that if I refuse to comply with signing a release when requested, it may be
grounds for my termination from Mental Health Court.
9. I agree to be truthful, cooperative, and respectful with the Mental Health Court Team.
10. I understand that based upon any report (written or oral) of my violation of this Consent to Participate, the
Mental Health Court Judge may: authorize a warrant for my arrest; impose any sanction, including jail time if
ordered by the Judge; adjust my treatment plan; or modify or revoke any conditions of my probation or bond.
My violation(s) may result in proceedings being initiated seeking my termination from the Mental Health Court
and these proceedings could either be resolved in Mental Health Court or be referred back to traditional court.
Iris Y. Martinez, Clerk of the Circuit Court of Cook County, Illinois
cookcountyclerkofcourt.org
Page 1 of 2
Consent to Participate Mental Health Court Program
(02/02/21) CCCR 0106 A
IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS
THE PEOPLE OF THE STATE OF ILLINOIS
v.
Case No. _______________
Defendant
CONSENT TO PARTICIPATE MENTAL HEALTH COURT PROGRAM
1.
I understand that I have no legal right to participate in the Mental Health Court Program. I have reviewed
this Consent to Participate with my Attorney and I hereby knowingly and voluntarily execute this Consent to
Participate which allows me to participate in the Mental Health Court Program.
2. I agree to participate in and cooperate with any and all treatment recommendations, including, but not
exclusively, any mental health or substance abuse assessments and/or treatment recommended by the Mental
Health Court Team, which consists of the Judge, Local PSC Coordinator, Prosecutor(s), Public Defender or
Defense Counsel, Probation, Treatment Provider(s), Case Manager(s) and any other personnel designated by the
Mental Health Court Team.
3. I understand that it is essential that all members of the Mental Health Court Team, including the Judge,
communicate as a team and share information regarding my participation in the Mental Health Court, including
compliance with treatment, and I agree to them doing so. Upon entry into the Mental Health Court, I consent
to the Mental Health Court public defender representing me at Mental Health Court staffings and at Mental
Health Court status review hearings unless I have privately retained counsel. I understand that my privately
retained counsel will be required to represent me at all staffings and Mental Health Court status review hearings.
In the event that my privately retained counsel is unable to attend staffings and/or court, I understand that
my attorney will arrange for other counsel to appear on my behalf.
4. I agree to adhere to all components of my treatment, including attending all counseling sessions, treatment
programs, taking my medication as prescribed, engaging in structured daily activities as recommended by the
Mental Health Court Team, and cooperation with home visits by Mental Health Court Team members.
5. I agree to remain drug and alcohol free (except for approved prescribed medications) and to submit to random
drug testing at the discretion of the Mental Health Court Team or any treatment provider and agree to the
disclosure of the results to the Mental Health Court Team. I understand that I may be sanctioned for providing
diluted, adulterated or substituted test specimens.
6. I agree to appear in court as required. I understand that my court hearings will be open to the public and an
observer could connect my identity with the fact that I am in treatment and I consent to this type of disclosure
to a third person.
7. I agree to reside in ________________________ County and to keep the Mental Health Court Team advised
of my current address and telephone number, employment status, and any new arrests at all times while in the
program.
8. I agree to sign any and all releases of information consenting to the disclosure of information to the Mental
Health Court Team. I understand that if I refuse to comply with signing a release when requested, it may be
grounds for my termination from Mental Health Court.
9. I agree to be truthful, cooperative, and respectful with the Mental Health Court Team.
10. I understand that based upon any report (written or oral) of my violation of this Consent to Participate, the
Mental Health Court Judge may: authorize a warrant for my arrest; impose any sanction, including jail time if
ordered by the Judge; adjust my treatment plan; or modify or revoke any conditions of my probation or bond.
My violation(s) may result in proceedings being initiated seeking my termination from the Mental Health Court
and these proceedings could either be resolved in Mental Health Court or be referred back to traditional court.
Iris Y. Martinez, Clerk of the Circuit Court of Cook County, Illinois
cookcountyclerkofcourt.org
Page 1 of 2
Consent to Participate Mental Health Court Program
(02/02/21) CCCR 0106 B
11. I understand that my alcohol, drug treatment and mental health records are protected by Part 2 of Title 42 of
the Code of Federal Regulations (CFR) and HIPAA; Illinois Mental Health and Developmental Disabilities
Confidentiality Act, 740 ILCS 110 et seq.; 45 C.F.R Parts 160 & 164. I understand that I may revoke this
Consent To Participate at any time except to the extent that action has been taken in reliance on it. In any event,
this Consent To Participate expires upon the termination of the probation I am serving in this case, or the
termination of all proceedings with regard to this cause of action as named above.
12. I understand that I may voluntarily withdraw from the Mental Health Court Program in accordance with the
Mental Health Court procedures. I understand that there may be consequences, actual or potential, which will
result from my withdrawal.
13. I understand that at the discretion of the presiding Mental Health Court Judge, for purposes of research
and/or education, other persons may be permitted to attend the Mental Health Court Team meetings where
communications as to my case will occur.
14. I understand that language help is available and if I need assistance, it is my responsibility to inform the court I
need help.
I understand that the Mental Health Court Program may be an opportunity for me to avoid conviction, jail
and/or prison and to help me obtain treatment and move forward with my life. I also understand that all
members of the Mental Health Court Team want to see me succeed and are here to help.
Date: ___________
Name
Signature of Interpreter
Signature
(Where applicable)
Signature of Parent or Guardian
(Where applicable)
I have reviewed this consent with the Defendant. The Defendant understands it and voluntarily agrees to
participate. I further understand that the Mental Health Court Team will be discussing the Defendant’s
compliance and cooperation with his/her treatment plan and terms of supervision at Mental Health Court
staffings and at Mental Health Court status review hearings. I acknowledge that if I remain Counsel of
Record for the Defendant, I will appear or arrange for other counsel to appear at Mental Health Court
team staffings when the Defendant is scheduled to be staffed by the Mental Health Court Team and also
appear at or arrange for other counsel to appear with the Defendant at all Mental Health Court hearings.
Date: ___________
_____________________________________________
Signature of Defense Counsel/Public Defender
Date: ___________ This Consent to Participate is accepted by: _______________________________________
Judge
Iris Y. Martinez, Clerk of the Circuit Court of Cook County, Illinois
cookcountyclerkofcourt.org
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