I,First Name   Last Name , have been informed by the School Counselor and understand the following:

1. I will participate in supportive individual and/or group sessions for skill building and education. I am aware that if I need more intensive services, I may be referred to out-patient services.
2. This is a voluntary program and I can withdraw from services at any time.
3. I have been informed of the confidentiality requirements and limits of confidentiality for participation in this program. Should I wish for the School Counselor to share information with another person or organization, I will be required to sign a specific release in order for them to do so.
4. I have been informed of important telephone numbers to include the Florida Abuse Hotline, Florida Disability Rights, and the Substance Abuse and Mental Health Program Office. Grievance procedures have also been reviewed.
5. This informed consent will be in effect for the 2025-2026 school year at  School Name* school.

I, the undersigned, understand the above explanations and give my consent to voluntarily participate in this prevention program.