DWI Intervention Consent for Release

Complete this form prior to the first day of the course.

"*" indicates required fields

Name*

I hereby consent to verbal and/or written or electronic communication between Education Resource and other elements of the criminal justice system including my lawyer, the judge, the probation department, and/or any other referring criminal justice agency.

The purpose of and need for disclosure is to inform the criminal justice agencies of my attendance and progression in the DWII program.

I understand that this consent will remain in effect until there has been formal and effective termination or revocation of my probation, conditional release, or other proceeding under which I was mandated to the services of Education Resource.

I also understand that any disclosure made is bound by Part 2, Title 42 Code of Federal Regulations governing confidentiality of client records.
Consent*