The Santa Rosa and Okaloosa RISE programs provide prevention counseling
services to students attending various schools in Santa Rosa and Okaloosa County, Florida. Individuals are referred by teachers, guidance counselors, administrators and parents or may self-refer for prevention information and education services. Individuals 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 andbuilding resistance skills.

I, First Name*   Last Name*, (parent/guardian) hereby give permission for my child, First Name*   Last Name*, 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.