CAUSE NO. THE STATE OF TEXAS IN THE DISTRICT COURT V. OF MONTGOMERY COUNTY, TEXAS JUDICIAL DISTRICT DEFENDANT

CAUSE NO. THE STATE OF TEXAS IN THE DISTRICT COURT V. OF MONTGOMERY COUNTY, TEXAS JUDICIAL DISTRICT DEFENDANT MONTGOMERY COUNTY MENTAL HEALTH TREATMENT COURT PROGRAM PARTICIPANT CONTRACT Name: Address: DOB: Cell No: _ Email: _ Employer: Phone: Emergency Contact: Phone: Please read this carefully and initial each term, indicating you understand the Montgomery County Mental Health Treatment Court policies and procedures and agree to participate under these following terms and conditions of participation in the Montgomery County Mental Health Treatment Court. The Mental Health Treatment Court reserves the right to modify this agreement with proper notice: In consideration of being accepted into the above-named Montgomery County Mental Health Treatment Court, you agree to abide by the following terms while you re in the program. By signing this document you are indicating that you voluntarily enter into this Contract and agree to be bound by its terms. I hereby agree to the following: _ I will obey all laws and report any new arrest or contact with law enforcement officials to the Court and Court Supervision Officer immediately. I will inform any law enforcement officer who contacts me or who I come in contact with of my enrollment in the Mental Health Treatment Court program. _ I understand that I will have to follow orders given to me by the presiding Mental Health Treatment Court Judge, Mental Health Treatment Court personnel, and other people involved in the Mental Health Treatment Court program. I understand that the probation officer, case manager, prosecutors, defense attorney, treatment providers and Court work together as a team. I will not blame my failure to report, submit to a UA or any other requirement as requested on communication with the Mental Health Treatment Court team. _ I agree to abide by all Court Orders, this includes but is not limited to No Contact Orders, Sanction Orders, and Orders to enter and complete treatment. REVISED SEPTEMBER 26, 2016

I agree to abide by the rules and regulations of the Montgomery County Community Supervision and Corrections Departments (MCDCSC) and follow all the Conditions of Supervision as ordered by the Court. I will promptly and truthfully answer all inquiries directed to me by all Mental Health Treatment Court Team members. _ I will appear at all scheduled court hearings or as ordered by the Judge or as directed by the Montgomery County Mental Health Treatment Court Team. I will be respectful of all court proceedings, and I will obey all courtroom rules. (1) I will be on time, dress appropriately, turn off my cell phone, not use foul language and be respectful to all Court staff. I understand there is NO talking or whispering in the gallery during Mental Health Treatment Court proceedings; (2) I will not call the Court to reschedule my Community Supervision Officer appointments nor my Community Supervision Officer to reschedule my Court appearances; and (3) I understand that if I miss a Court appearance I may be sanctioned. _ I will comply with all program requirements, including but not limited to: a) Being on time and attending all Mental Health Treatment Court appearances; b) Being on time and attending all treatment sessions; c) Participating in all treatment sessions; d) Completing all treatment assignments; e) Making satisfactory progress in the program as measured by phase requirements; f) Notifying my treatment provider and Community Supervision Officer of any drugs prescribed for me by a physician before I begin taking them; and g) Providing written notification to my physician that I am in Mental Health Treatment Court. I will contact my Community Supervision Officer as directed. _ I agree to participate in the Montgomery County Mental Health Treatment Court Program until successful completion or until I am discharged. _ I will not violate city, state, or federal law. _ I understand that if I engage in any criminal act, I may be removed from the Mental Health Treatment Court program and prosecuted for any new charge(s). _ I will not commit acts of violence or threats of violence. I will not engage in verbal violence _ I will not possess, use, own, or have under my control, any firearm, nor will I reside where firearms are present. Any exception as to residence requires prior written approval from the Court. I understand that I may owe court costs, supervision fees, lab fees, program fees, fines, treatment fees, restitution (if applicable). I understand that my probation fees will be waived during Phase 1 of the Mental Health Treatment Court. I will enter into and successfully complete all treatment deemed necessary by the Court. I will abide by all rules/regulations set by the treatment providers and all conditions and requirements ordered by the Court. Page 2 of 11

I will sign all Releases of Information as deemed necessary by the treatment provider, the Montgomery County Community Supervision and Corrections Department (CSCD), and the Mental Health Treatment Court. I will reside in Montgomery County, Texas or a contiguous county if approved by the Court. Without first notifying and obtaining permission from the Court I will not: 1) change residences; 2) spend the night at any address other than the one that has been approved by the court; 3) travel out of county/state; or 4) change my telephone number; or 5) employment. I will immediately notify my Community Supervision Officer and the Court of any unforeseen changes in residence. I understand that I must be employed, or in school, or in treatment, or involved in an approved activity that supports recovery through my participation in the Montgomery County Mental Health Treatment Court. I will not associate with or be near anyone who is under Community Supervision (Probation), on Parole, currently incarcerated or has a criminal record unless they are attending a Mental Health Treatment Court, treatment session, 12 Step or support group meeting or living with me in transitional housing without express permission from appropriate Mental Health Treatment Court Personnel before the contact takes place. I will not engage in sexual behavior of any type with another Mental Health Treatment Court client. I understand that as a result of infractions identified by the Mental Health Treatment Court Team or Treatment Provider, certain sanctions may be imposed. Court ordered sanctions include but are not limited to: Judicial reprimands Increased frequency of court appearances Increased frequency of office and/or home visits with Community Supervision Officer Rotated to the bottom of the docket Placed on a behavior contract Delay in phase advancement or regress to a prior phase Required to write an essay Loss of privileges (curfew, travel) Imposition of community service Issuance of a Bond Forfeiture or Warrant Jail remand Termination from Mental Health Treatment Court Program Revocation of my deferred adjudication or community supervision, allowing the court to then convict and sentence me within the full range of punishment. I understand that the Mental Health Treatment Court Team and/or treatment provider may determine that my actions warrant a clinical response. These clinical responses include but are not limited to: Recommendation to treatment provider to modify treatment plan Increased frequency of 12 Step Meetings or other pre-approved support group meetings Mandatory group meetings (anger management; time management; money management) Hospitalization (voluntary or involuntary) Substance abuse treatment (Detox, Secure, Residential, IOP, SOP) Transfer to a more restrictive or less restrictive housing or treatment program Page 3 of 11

Increased or decreased frequency in medication monitoring Increased or decreased contact with Mental Health Treatment Court Team I understand that if I violate the terms of this agreement, I am still expected to comply with and follow Court directives and treatment recommendations. I understand that due to the waiver I have signed, the Mental Health Treatment Court can, in some cases, impose additional sanctions in the event of a finding that this agreement has been violated. I further understand that I have the right, with my attorney, to present my explanation to a Mental Health Treatment Court Judge at the first opportunity. I acknowledge that I have been informed that if the Court, in its sole discretion, finds that I willfully failed to comply with any treatment and/or rehabilitation requirements, I may be revoked from the program and the Court may proceed to impose sentence. I understand that my failure to successfully complete the Mental Health Treatment Court program will result in re-instatement of criminal proceedings against me. I understand that my failure to complete the Mental Health Treatment Court Program cannot be a basis for withdrawing my previously entered guilty plea. I will perform any and all community service hours which may include a required community service project as directed by the Mental Health Treatment Court. Alcohol and Drugs I will not possess or use alcohol or drugs unless lawfully prescribed in writing by a physician, in which case I will notify my community supervision officer, court personnel or treatment provider before taking the medication. I will also provide copies of prescriptions at my next contact with the court or staff. I will not possess, buy, sell or consume any substances that are herbal incense, potpourri, bath salts and/or any non-prescribed mind or mood altering substances. Such substances include, but are not limited to: Spice, K2, Mr. Nice Guy, Salvia and Brainfreeze. I understand and agree that although these mind-altering substances may not currently be illegal, I understand and agree that any possession, use, buying or selling by me of these substances, will result and be treated as a use sanction/penalty within the Montgomery County Mental Health Treatment Court Team and will impact my progression through the program. I will not associate with or be near anyone who is using/possessing any illegal/controlled substance, synthetic cannabinoids (such as K2, Spice), or synthetic amphetamines/cocaine (such as Pure, Bliss). I understand that I am not to enter into any smoke shops or any known business or businesses related to smoke shops. I understand that I am not to go into bars, liquor stores, taverns, clubs, parties, or places where alcohol is the main item for sale or consumption. I will not visit places where illegal drugs are sold, dispensed, or used. I understand that while participating in a Mental Health Treatment Court I cannot consume alcohol. Page 4 of 11

I understand that while participating in a Mental Health Treatment Court, I am not to consume NON-ALCOHOLIC beverages (such as ODULES, etc.). Prescription Medication _ I understand that I am to inform all health care providers that I have a co-occurring disorder, and may not take narcotic or addictive medications or drugs. If a treating physician wishes to treat me with narcotic or addictive medications or drugs, I must disclose this to my treatment provider and get specific permission from the Mental Health Treatment Court Team to fill the written prescription and take such medication. I also must obtain a doctor s signature on the Doctor s letter provided by the Mental Health Treatment Court Team and return such letter to the Court immediately within 48 hours of my appointment. I understand that I will request, whenever possible, that any medication prescribed by a licensed health care provider be a non-narcotic. I will seek approval from my Community Supervision Officer and the treatment provider for any over-the-counter or prescribed medication prior to using such medication and I will take such medication as prescribed. Use of prescription drugs, other than psychotropic and antibiotic medications may impact my clean time and movement through my Montgomery County Mental Health Treatment Court phases. _ I understand that I am to provide the Court and Community Supervision Officer with a copy of all daily prescription and over the counter medications, including the milligrams and amounts taken throughout my participation in the Mental Health Treatment Court program. I understand that I am required to notify the Court and Community Supervision Officer of any new prescription and over the counter medications immediately while in the program and for as long as I remain in the program; I understand that I AM NOT to take any prescription medications that are not prescribed to me. Treatment _ I understand and consent to completing substance abuse and/or mental health screenings and/or evaluations throughout the duration of my participation in this Mental Health Treatment Court program. I will submit to rehabilitative, medical, psychological, psychiatric, educational, vocational, alcohol, or other drug treatment and aftercare programs, including residential treatment, as directed by the Mental Health Treatment Court. I understand that I am expected to enroll and participate in all treatment program(s) ordered by the Court I understand and consent to a program being developed specific to my case and understand and consent to that program being changed throughout the duration of my participation in the abovenamed Mental Health Treatment Court. _ I understand and consent to participating in specialized programs and/or caseloads designed to help me avoid further legal action Page 5 of 11

I agree to take psychiatric medications as prescribed by my licensed health care provider and that are approved by the court. I agree to attend and participate in all psychiatric and/or counseling sessions if the Mental Health Treatment Court Team deems it necessary. I understand that I am not to leave any treatment program without prior approval of the Mental Health Treatment Court Team. I understand that my individual course of treatment may include in-patient treatment, residential treatment, Intensive Outpatient Treatment (IOP), Supportive Out Patient Treatment (SOP), Aftercare groups, education, and/or self-improvement courses such as anger management, parenting or relationship counseling. I understand that, if ordered to residential treatment or certain types of housing, I may have to remain in custody until the facility or housing has availability. I understand that I am to abide by all policies and procedures at the facility at which I attend treatment. If the court sanctions me by sending me to jail, or I am arrested on a warrant, or I am arrested on a new offense, I will notify the jail of my mental status and, if applicable, my current medications. Drug Testing _ I agree to submit to witnessed urine, breath, or other screening at any time, even if not on my testing day, as directed by the random call in system or any member of the Mental Health Treatment Court Team or Treatment Provider. I understand that if, at the time of request, I refuse or fail to provide a specimen for a drug screen, the Mental Health Treatment Court will consider my action a program violation and I may be sanctioned. I understand any attempt on my part to dilute or alter any type of drug test specimen, either through use of a foreign device, consumption of a masking agent, or any other means, will result in a sanction and may result in my immediate termination from the program. I understand that if my UA is DILUTE it could be considered a possible positive and I will need to re-submit immediately. (If you leave without re-submitting, you are subject to sanctions). I understand that I will be advised of the procedures for submitting to a drug screen. I understand if I miss a drug test for any reason, I am required to test the next day. I understand that if I admit to using and my drug screen comes back positive for any other substance other then what I admitted to, I will be subject to additional sanctions; I understand that if I am taking vitamins, any type of work out supplements or consume energy drinks of any kind that they will not show positive for alcohol or drugs on my UA testing, drug patch results or DLD results. Page 6 of 11

I understand that if taking the required amount of approved over the counter cough syrups such as Nyquil, it will not show positive for alcohol on my UA test. (You should never take more than the recommended dose, and only take medications approved by your case manager). DRUG PATCH (if applicable) _ I understand and agree to pay the fee each time my drug patch is applied or replaced. (The patch is replaced every two weeks and the price is subject to change by the providing company). _ I understand that my failure to have the drug patch applied, replaced or removed as Ordered by the Court may result in a sanction being imposed. _ I understand that if I report and my drug patch has been removed or is missing, this is considered to be a positive. This may result in a sanction being imposed. _ I understand that tampering with or removal of the patch by me or anyone other than a Recovery Health Care Technician may result in sanctions being imposed. _ I understand that if my drug patch comes back positive for any illegal substances or substance in which I do not have a valid prescription for it may result in sanctions being imposed. _ I understand that if my patch comes back positive for any illegal substance and I advise the Court that I did not consume such substance in any way, but that I was around others that did, I am subject to a positive patch and sanctions being imposed accordingly. DLD (Deep Lung Device)/SCRAM _ I understand that if I am on probation for a DWI or any alcohol related offense, I am required by law to have the DLD on my vehicle at a minimum of fifty percent (50%) of the length of my probation. _ I understand that when I have completed 50% of my probation term and am allowed to request the DLD be removed from my vehicle, that it is at the discretion of the Mental Health Treatment Court Team. _ I understand that I am not to operate any motor vehicle that is not equipped with a DLD. (If required by law for an alcohol related offense, or it was Ordered by the Court). _ I agree to sign an Affidavit that I am not driving and will not drive a motor vehicle. (If I am on probation for a DWI, alcohol related offense or my license has been suspended). _ I understand that if I was not driving when I entered the program and obtain an Occupational Driver s License ODL at a later date and am on probation for a DWI or alcohol related offense, I am required to have the DLD installed immediately before driving. _ I understand that if I am required to have the DLD and I fail to submit to a breath test, rolling test, scheduled test, calibration, tampering with the device or abide by any additional conditions as required by this Court, it may result in sanctions being imposed. Page 7 of 11

_ I understand that if I am required to have the SCRAM and I fail to submit to a download as required, tampering with the device or abide by any additional conditions as required by this Court, it may result in sanctions being imposed. ADDITIONAL WAIVERS _ Legal Waiver: I do hereby release and forever discharge the complaining witnesses, victim(s), the Mental Health Treatment Court Judge, the County and Prosecuting Attorney s Office, the Defense Attorney, Mental Health Treatment Court, Law Enforcement Personnel, Department of Corrections Probation & Parole, the Mental Health Treatment Court Staff, and their respective heirs, successors, executors, administrators, and assigns from any and all claims of any kind or nature whatsoever, either in law or in equity, arising out of my arrest, participation in, or termination from, the Mental Health Treatment Court, and do expressly release and forever hold them harmless from any criminal or civil action which I may have a right to bring as a result of my arrest or participation in the Mental Health Treatment Court. _ Ex Parte Communication Waiver: The exchange of information regarding clients that occurs between team members in staffing before court appearances is a key component of a successful Mental Health Treatment Court program. The Judge presiding over the Mental Health Treatment Court program is a part of the staffing and may receive information about you from treatment providers, probation officers, law enforcement officers, prosecutors, social workers and others. This is information that would be received by the Judge in the absence of you or your attorney is known as an ex parte communication. I understand and agree and waive any objection to the Judge initiating, permitting or considering such ex parte communication in my absence. _ Status of Program: I have no legal right to participate in the Mental Health Treatment Court. At any time, the Program may be ended restricted or reduced, or I may be excluded from it. _ Self Help Groups: Program rules require participation in self-help groups to support recovery. Some of the groups include but are not limited to Alcoholics Anonymous and Narcotics Anonymous. Participants may ask the Mental Health Treatment Court Team Members for current programs that qualify. The participant will be required to provide attendance confirmation consistent with the operational procedures of the self-help group and the court. _ Waiver of Right to Remain Silent: I give up my right to remain silent regarding compliance with the Mental Health Treatment Court Program. I agree to fully and HONESTLY participate in all Mental Health Treatment Court meetings. _ Searches: a) I will submit to random searches of my person, vehicle or residence at the request of Probation and Parole and/or law enforcement for controlled substances, alcohol or any paraphernalia. I am aware that law enforcement will be conducting random home visits, with or without my probation agent, as a part of my participation in the program, and b) I will be subject to search of person and property by treatment provider staff or designee while participating in treatment programming or while on treatment provider property. Failure to comply with these requirements may result in sanctions or termination. _ Confrontation: I waive any right to confront and cross-examine any witnesses concerning results of any confirmed drug test while a participant in the Mental Health Treatment Court program other than for purposes of revoking the term of community supervision. Page 8 of 11

_ Contested Hearing: I waive any right to have a contested hearing on violations which may occur while participating in the Mental Health Treatment Court program unless the hearing could result in revocation of the term of community supervision. _ Modification of Community Supervision: I waive any right to a hearing on any modification made to the terms of my community supervision unless the modification involves the revocation of the term of community supervision. _ Attorney Presence: I waive any right to have an attorney present during proceedings which may occur while I am a participant in the Mental Health Treatment Court program unless proceedings may result in revocation of term of supervision. FREE, VOLUNTARY, KNOWING AGREEMENT My participation in the Program requires that I waive very important rights. I have fully discussed my rights with my lawyer, or I have had an opportunity to consult with a lawyer before agreeing to enter the Program. I am satisfied that I understand how the program will affect my rights. At the time of executing this document, my thinking is clear and I am not under the influence of any substance. The decision to waive my rights and enter the Program is mine alone and made of my own free will. I expressly agree to accept and abide by all the terms and conditions of the Mental Health Treatment Court as established by the Court and the Treatment Provider. PARTICIPANT ATTORNEY FOR PARTICIPANT BAR NO. ATTORNEY FOR THE STATE OF TEXAS BAR NO. The foregoing Agreement having been presented to the Court in open court with Participant and his/her Counsel present, and the Court being satisfied that Participant understands the rights that the Participant is freely and voluntarily waiving, the Court hereby accepts and approves Participant s waivers and this Agreement of Participant and the State HON. LISA MICHALK Page 9 of 11

Drug Testing Disclosure As part of the Mental Health Treatment Court Program Contract, I have been advised of the rules for the random drug testing line and I understand they are as follows: (May be different for each court) _ I understand that I am required to call the UA drug testing line every day no later than 9:00 AM, Monday-Saturday; _ I understand that if I am instructed to test, I am required to submit a sample by the end of business on the same date; _ I further understand that if I am instructed to test and I fail to do so, this will be considered a refusal and sanctions may be imposed accordingly; _ I also understand that if I fail to call in by 9:00 AM, I am still responsible to submit to a test on the same business day it is requested. (Example, if you forget to call until 3PM and a test is required, you must test); _ I also understand that I will be randomly called to submit a UA and will be required to submit by the end of business on the same date. MENTAL HEALTH TREATMENT COURT PARTICIPANT SUPERVISION OFFICER Page 10 of 11

MENTAL HEALTH TREATMENT COURT PARTICIPANT CONSENT _ CONSENT FOR DISCLOSURE OF CONFIDENTIAL SUBSTANCE ABUSE INFORMATION I,, hereby consent to communication between and, and any person(s) assigned or designated to the Mental Health Treatment Court Team. The purpose of, and need for, this disclosure is to inform the Court and all other named parties of my eligibility and/or acceptance for substance abuse treatment services and my treatment attendance, prognosis, compliance and progress in accordance with the Mental Health Treatment Court Program s monitoring criteria. Disclosure of this information may be made only as necessary for, and pertinent to, hearings and/or reports concerning the criminal charges against me. I understand that this consent will remain in effect and cannot be revoked by me until there has been a formal and effective termination of my involvement with the Mental Health Treatment Court Program for the above referenced case I understand that any disclosure made is bound by Part 2 of Title 42 of the Code of Federal Regulations, which governs the confidentiality of substance abuse patient records and that recipients of this information may re-disclose it only in connection with their official duties. Signature Printed Name Social Security Account Number Date of Birth Date Signed Page 11 of 11