Free CCJP 0662 4-08-05.pmd - Illinois

Order for Release of Mental Health Records STATE OF ILLINOIS COUNTY OF COOK

(Rev. 4/08/05) CCJP 0662 4351

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IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS DEPARTMENT OF JUVENILE JUSTICE AND CHILD PROTECTION CHILD PROTECTION DIVISION IN THE INTEREST OF:

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Minor(s)

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No. ____________________________

ORDER FOR RELEASE OF MENTAL HEALTH RECORDS
THIS MATTER COMING on to be heard before the Honorable _____________________________, the parties being present and/or represented by counsel, and the Court being fully advised in the premises, and pursuant to the Mental Health and Developmental Disabilities Confidentiality Act, 740 ILCS 110/4 (a) (5) and 110/10 (d); IT IS HEREBY ORDERED THAT:

_______________________________________________________________ shall release to the Offices of the
Cook County Public Guardian (2245 West Ogden Avenue, Chicago, IL 60612), the Cook County State's Attorney (2245 West Ogden Avenue, Chicago, IL 60612) and __________________________

_____________________________, certified and delegated copies of all records relating to _______________ _____________________________, (date of birth) ______/______/______, including but not limited to records
of the psychiatric and/or psychological hospitalization, evaluation and/or treatment. ENTERED: Dated: ________________________, _________ Atty. No.: ________________ Name: ______________________________________ Atty. for: ______________________________________ Address: ______________________________________ City/State/Zip: ___________________________________ Telephone: ____________________________________
DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS

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Judge Judge's No.