CDAC Behavioral Healthcare, Inc.
Santa Rosa and Escambia RISE School ProgramsParent Consent for Services
The Santa Rosa and Escambia RISE programs provide prevention counseling services to students attending various schools in Santa Rosa and Escambia County, Florida. Students are referred by teachers, guidance counselors, administrators and parents or may self-refer for prevention information and education services. Students may participate in individual and/or group support services to enhance protective factors by developing social competency skills, such as positive communication; fostering prosocial peer relationships; developing pro-social behaviors; improving academic performance and commitment to school, and building resistance skills.I, *, (parent/guardian), hereby give permission for my child, * , to participate in the RISE program. In addition I understand that my child’s records maintained by this program are protected under the federal regulations governing Confidentiality of Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 C.F.R. Pts. 160 & 164 and cannot be disclosed without his/her written consent unless otherwise provided for in the regulations.