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

1. I will participate in prevention groups and/or individual sessions.
2. This is a voluntary program, and I can withdraw from services at any time.
3. I have been informed of the confidentiality requirements for participation with this program. I understand that I hold responsibility for the confidentiality of other group members, and that anything I reveal to the School Counselor is confidential except a plan to harm self or others, self-harm behaviors to include cutting self, burning self or other self-mutilation, or suspicion of sexual or physical abuse. 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 and given a copy of the Rules of Student Conduct and important telephone numbers to include the Abuse Report Hotline, the Disability Rights Florida, and the Substance Abuse and Mental Health Office.
5. This informed consent will be in effect for the 2024-2025 school year.

I, the undersigned, understand the above explanations and give my consent to voluntarily participate in this prevention program. If I have further questions, I can contact the School Counselor.