I consent to disclosure by the CDAC Behavioral Healthcare, Inc. RISE Program of confidential information concerning my participation in the above-mentioned Program as follows:

• Names of person or title and organization to/from whom disclosure is to be made:
  • To/From: School Faculty/Administration and School District/Integrated Services Team.
  • To/From: Parent/Guardian.
• Specific type of information to be disclosed to CDAC:
  • Student attendance, school information, achievement, and discipline records.
• Specific type of information disclosed by CDAC:
  • Attendance, behavior in groups, group topics and feedback/clarification to parents/guardians and/or school personnel at student request.
  • Any information that may impact personal or school safety.
• Purpose or need for such disclosure:
  • To provide agency with background information for prevention implementation and activity planning purposes.
  • To facilitate feedback and resolution of area of concern.

I understand that my 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 my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent in writing at any time except to the extent that action has been taken in reliance on it, and that in any event this consent shall have a duration no longer than
# of months* months.