Social Skills Groups Client Forms

Informed Consent for Psychoeducational Group

Social Skills Group


We are pleased to offer a Social Skills Group, which is designed to provide opportunities for children to learn and practice social skills in a safe and supportive environment. This program is led by trained professionals who have experience working with children in this area.

The state expects that you will be informed of all possible contingencies that might arise in the course of any interaction with a Licensed Marriage & Family Therapist, including the psychoeducational groups indicated above. It is important to be clear about the nature of a psychoeducational group experience. Please read the information below and raise any questions that you may have so that we can discuss them.

Service Provider: Bee-Yu (Ariel) Yung, The Child and Family Connection

Registration: Licensed Marriage and Family Therapist, California Board of Behavioral Sciences #LMFT 108189

Credentials: I am a Licensed Therapist in the state of California. Areas of specialization include early childhood development, poor coping/emotional regulation issues, depression, anxiety, trauma/PTSD, ADHD, disruptive behavior, parenting skills, and relationship issues.

Description of the Program:

The Social Skills Group is a program that provides a fun and interactive way for children to learn and practice social skills. This social skills group course is designed to teach your child important and essential pro-social skills in a fun and engaging manner. Each week, we will be focusing on a different topic area including Getting to know one another, Friendship/making & keeping friends, Sharing/taking turns, Listening/following directions, Managing emotions/healthy coping skills, Manners, Kindness/empathy, and Teamwork/cooperation. Each week’s lesson is specifically crafted to be for your child’s developmental level, accompanied by related age-appropriate activities which allows your child to practice the skills taught in a safe, non-judgmental, and nurturing environment. As the Facilitator, I will be using prompting, coaching, redirection, feedback, and positive reinforcement to guide/assist your child in navigating through various social scenarios/situations with his/her peers.

Within this social skills group course, not only will your child have the opportunity to meet and connect with other kids his/her age, your child will also learn how to interact with his/her peers in a more positive and socially appropriate manner, which will in turn allow your child to have deeper, more meaningful relationships with others later on in life.

Psychoeducation vs. Psychotherapy:

You understand that this psychoeducational group experience is purely “educational” in design and purpose, and is not “therapeutic" (i.e., it is NOT a replacement for individual therapy or for group therapy). In these psychoeducational group sessions, I will serve as the facilitator and present to attendees scientific and theoretical material that is applicable to various life circumstances and problems, and there will be ample time for discussion. If issues arise that are not suitable for this educational experience, you may benefit from formal psychotherapy and you agree to consult with me and/or another mental health professionals to obtain referral information. You realize that you may obtain formal psychotherapy services from Bee-Yu (Ariel) Yung, LMFT upon arrangement, but you realize that these psychotherapy services are entirely distinct and separate from the psychoeducational group experience.

Goals of the Program:

The primary goals of the Social Skills Group are:

  • To help children learn and practice social skills in a supportive and engaging environment.
  • To provide opportunities for children to interact with peers and develop positive relationships.
  • To improve children's self-esteem and confidence in social situations.
  • To promote emotional regulation and coping skills.

Risks and Benefits:

Participating in a psychoeducational group experience can have benefits and risks. Psychoeducation has been shown to have many benefits, including the experience of insight, increased understanding, and positive feelings. However, since psychoeducation may involve discussing many parts of your life, including, at times, the unpleasant aspects, you may also experience uncomfortable feelings. You should be aware that psychoeducation may or may not lead to direct improvements in your life. You should also be aware that if psychoeducation induces change in your life, these changes may disrupt your accustomed manner of living and your relationships with others.

The benefits may include:

  • Improved social skills, including communication, cooperation, problem-solving, and empathy.
  • Increased self-esteem and confidence in social situations.
  • Opportunities for positive social interactions and relationship-building with peers.
  • Improved emotional regulation and coping skills.

Your Rights:

In a private practice such as this, psychoeducation is entirely voluntary and you have the right to terminate your experience at any time. In all cases, psychoeducation never includes sexual contact with the facilitator. Please be advised that I also reserve the right to terminate your involvement in psychoeducation if recommended consultations are not obtained, or if some problem emerges that is not within the scope of my competence.

Protecting the Confidentiality of Other Attendees:

With full understanding of the need for confidentiality (that is, privacy) for all attendees, you accept these following rules:

  1. You will not disclose personal information about other attendees to anyone;
  2. other information (such as phone numbers) can be exchanged between attendees only on a person-to-person basis;
  3. any activity between attendees outside of the psychoeducational group experience is solely based on the choice of these attendees and is not the responsibility of the facilitator. You understand that you cannot be absolutely certain that other attendees will always keep what you say in the sessions confidential even though every attendee has agreed to secrecy. The other attendees do not serve in the role of facilitator/LMFT and are therefore not obligated to maintain the same ethics and laws that the facilitator must work under.

About the Relationship with the Facilitator:

Because of the nature of the psychoeducational group experience, the relationship between the facilitator (Bee-Yu Yung, LMFT) and the attendees has to be different from most relationships. It must be limited to the relationship of facilitator and attendee only. If we were to interact in any other ways (including socially, business, legal, medical, financial, sexual or romantic) we would then have a “dual/multiple relationship” and violate important ethical principles for Licensed Marriage & Family Therapists (LMFTs). LMFTs are obligated by legal and ethical mandates to avoid dual relationships situations so as to protect the public. You should also know that LMFTs are required to keep the identity of their clients (and psychoeducational group attendees) private and confidential. Lastly, when our work together in this psychoeducational group experience is completed, I will not be able to be a friend to you like your other friends or engage with you in any way socially or romantically. In sum, my duty as facilitator/LMFT is to care for you and my other clients, but only in my professional role.

Limits of Confidentiality:

The law protects the privacy of all communications between client and a LMFT. In most situations, the LMFT can only release information about his/her work with you to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA. However, there are some exceptions in which a LMFT may be permitted or is required to disclose confidential client information without either the client’s consent or authorization. These situations including the following:

  1. If I have reasonable cause to believe (i.e., reasonable suspicion or evidence) based on a client’s communication that a child under age 18 is suffering physical or emotional injury resulting from abuse inflicted upon him or her which causes harm or substantial risk of harm to the child's health or welfare (including sexual abuse), or from neglect (including malnutrition), the law requires that I file a report with the appropriate social service (Child Protective Services) and legal authorities. In addition, if a client reports that he/she was physically or sexually abused as a child, or engaged in sexual acts with an adult while a child, and the reported perpetrator currently has access to children, the law requires that I file a report with the appropriate social service (Child Protective Services) and legal authorities.
  2. If I have reason to believe an elderly or handicapped individual is suffering from abuse or maltreatment, the law requires that I file a report with a law agency and/or the State Department of Social Services.
  3. If a client communicates an immediate threat (i.e., with clear intentionality of harm or a plan to harm) of serious physical harm to an identifiable victim, I may be required to take protective actions. These actions may include notifying the potential victim, contacting the police, and/or seeking hospitalization for the patient.
  4. If a client threatens to harm himself/herself (i.e., communicates intent and/or a plan for suicide), I am required to notify legal authorities and make reasonable attempts to notify the client’s family members or others who can help provide protection.
  5. If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself.

Professional Records:

You have specific rights with regard to your clinical record. Your file will remain active while you are participating in treatment. When our work concludes, or it has been at least 30 days since our last contact, your file will be closed. You may request amendments to your record, request to restrict the information disclosed to others, request an accounting of disclosures, and determine the location to which protected health information is sent (please see my Notice of Privacy Practices for more information). The laws and standards of my profession require that I keep treatment records. Except in specific circumstances, you are entitled to examine your child’s clinical record and/or receive a copy at a rate of ¢25 per page. If you wish to see you or

your child’s records, you must request to do so in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. In the event that you do review the full records I recommend that they are reviewed in my presence so that we can discuss the contents. Clients will be charged an appropriate fee for any professional time spent in responding to information requests. You may request that any complaints you have about my privacy policies and procedures be

Fee for Service & Insurance:

My fee is $150.00 per 120-minute psychoeducational group session (or a total of $600.00 for all 4 group sessions. Payment is due at the beginning of each group session. Credit card information will be collected prior to the start of the group and $150.00 will be charged for each session.

Unpaid Balances:

There will be a returned check fee of $25.00 should there be any problems clearing your check. If for any reason you do not pay your bill at the time of service, a $50.00 late fee will be assessed for each 30-days that you do not pay. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through a small claims court. If such legal action is necessary, its costs will be included in the claim. In most collection situations, the only information I release regarding a client’s treatment is their name, the nature of services provided, and the amount due.

Other Requests (Forensic Activity, Letter-Writing, and Release of the Medical Record)

The professional services provided to you in my practice are limited to those that are clinical and psychoeducational in nature. This is to ensure that I maintain a singular role with you, a role that represents my expertise. Given this, please be aware of the following potential requests that would directly or indirectly place me outside of my role:

  1. I do not have an expertise in forensic matters. Consequently, if you currently have, or plan to address, a legal situation in which you seek my involvement as your psychologist, I am not the best choice. Functions such as conducting court-related evaluations, providing letters to attorneys and/or judges, testifying in court, serving as your court-mandated treatment provider, etc. require highly specialized training, are outside of the scope of my professional competence, and are better suited for forensic practitioners. My potential participation in these activities merges therapeutic and forensic roles and, in most circumstances, is unethical.
  2. Requests for additional administrative services (such as, but not limited to, assessment of disability certification or advocating for special accommodations related to a psychological condition) will

have to be provided by another psychologist in accordance with the rationale indicated above, i.e., these types of professional activities are forensic in nature and should not be conducted by a psychologist acting within a clinical or psychoeducational role.

  1. As alluded to in point (a) above, letters are occasionally requested of their therapist by clients. Generally, the Board of Psychology in California and/or the Board of Behavioral Sciences and legal/ethical experts encourage clinicians to refrain from letter-writing as most letter requests are related to legal matters. Consequently, if a clincian agrees to write such a letter, he or she risks exposure to a legal action and, also, the letter itself may be construed as a professional action that is outside of the clinical or psychoeducational role. In most situations I will opt out of writing letters and will refer the client to an appropriate professional who can address the need at hand.
  2. Technically, the medical (treatment) record is the possession of the client. Because you are engaging in psychoeducation and not formal treatment, you technically will not have a treatment record. What will be recorded is any communication you have with me, the dates of your attendance in psychoeducational sessions as well as a summary of topics discussed, and fees paid. When a client provides authorization for the release of the record to a third party, it is incumbent upon the clinician to discuss with the client the circumstances regarding the release of the record and the potential risks involved. In many situations, it is often legally and clinically prudent for a summary of the record to be released (rather than the entire record). In addition, when treatment (or any specific session within a course of treatment) consists of more than one party involved in a session, in most situations the record or any portion of the record can be released only if the expressed written consent/authorization of all parties involved has been obtained. Finally, as indicated above, an administrative fee rate is applied to the time it takes for the preparation of materials associated with the release of a medical record.

Arrival at The Child and Family Connection:

When you arrive at our office, please follow the signs for the Social Skills Group. Parents are expected to bring their child to group sessions personally (unless arranged in advance with The Child and Family Connection) and must stay in the waiting room or immediate area during the session, as parents need to be able to be reached in case of any emergencies. Additionally, parents are also expected to be on hand to take a child to the restroom during group sessions, as needed.

Please be aware that I will be unavailable to take your call during social skills group time, as I am busy running/facilitating group at that time. However, in the event that you need to contact me, please call or text to my confidential voice mailbox (949)

221-4315. I check my messages a few times a day Monday through Saturday, unless I am away from the office. If an urgent situation arises, please indicate it clearly in your message and I will get back to you as soon as possible. However, in the event of a real emergency and you need to talk to someone right away, please dial 911 or go to your nearest hospital emergency room.

Agreement for Psychoeducational Group

By signing below, you show that you have read and understood the policies described above and agree to abide by this “Informed Consent for Psychoeducational Group”. If you have any questions as we progress with therapy, you can ask me at any time.
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The patient and/or guardian are ultimately responsible for payment of all services. As a result, it is our policy to have a credit/debit card on file for each patient. Check or cash is otherwise accepted at time of visit.

Billing Address:


I agree to be responsible for the per social skills group fee of $150.00 and authorize The Child and Family Connection to charge my credit card for the amounts due. I certify that I am the authorized user of this credit card and that my signature below indicates that I have read this Agreement and agree to its terms and conditions.
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HIPAA for Psychoeducational Group

Social Skills Group

Required HIPAA Notice of Privacy Practices



I am legally required to protect the privacy of your PHI, which includes information that can be used to identify you which I have created or received about your past, present, or future health or condition, the provision of health care to you, or the payment of the health care. I must provide you with this Notice about my privacy practices and such Notice must explain how, when, and why I will “use” and “disclose” your PHI. A “use” of PHI occurs when I share, examine, give, or otherwise disclose to a third party outside of my practice. With some exceptions, I may not use or disclose any more of your PHI than is necessary to accomplish the purpose for which the use or disclosure is made. I am legally required to follow the privacy practices described in this Notice; however, I reserve the right to change the terms of the Notice and my privacy policies at any time. Any changes will apply to PHI on file with me already. Before I make any important changes to my policies, I will promptly change this Notice and post a new copy of it in my office.


I will use and disclose your PHI for many different reasons. I will need your prior written authorization for some of these uses or disclosures; for others, however, I do not. Listed below are the different categories of my uses and disclosures along with some examples of each category.

A. Uses and Disclosures. Relating to Treatment, Payment, or Health Care Operations Do Not Require Your Prior Written Consent. I can use and disclose your PHI without your consent for the following reasons:

For Treatment. I can use your PHI within my practice to provide you with mental health treatment. I can disclose your PHI to physicians, psychiatrists, psychologists, and other licensed health care providers who provide you with health care services or are involved in your case.

To Obtain Payment for Treatment. I can use your PHI to bill and collect payment for the treatment and services provided by me to you. For example, I might send your PHI to your insurance company or health plan to get paid for the health care services provided to you. I may also provide your PHI to my business associates, such as billing companies, claims processing companies, and others that process health care claims.

For Health Care Operations. I can use and disclose your PHI to operate my practice. For example, I might use your PHI to evaluate the quality of health care services that you received or to evaluate the performance of the health care professionals who have provided such services to you. I may also provide your PHI to my accountant, attorney, consultants, or others to further my health care operations.

For Patient Incapacitation or Emergency. I may also disclose your PHI to others without your consent if you are incapacitated or if an emergency exists. For example, your consent is not required if you need emergency treatment as long as I try to get your consent after treatment is rendered; or, if I try to get your consent but you are unable to communicate with me (for example, if you are unconscious or in severe pain) and I think that you would consent to such treatment if you were able to do so.

B. Certain Other Uses and Disclosures Also Do Not Require Your Consent or Authorization. I can use and disclose your PHI without your consent or authorization for the following reasons:

1. When federal, state, or local laws require disclosure. For example, I may have to make a disclosure to applicable governmental officials when a law requires me to report information to governmental agencies and law enforcement personnel about victims of abuse or neglect.

2. When judicial or administrative proceedings require disclosure. For example, I may have to use or disclose your PHI in response to a court or administrative order if you are involved in a lawsuit or claim for workers’ compensation benefits. I may also have to use or disclose your PHI in response to a subpoena.

3. When law enforcement requires disclosure. For example, I may have to use or disclose your PHI in response to a search warrant.

4. When public health activities require disclosure. For example, I may have to use or disclose your PHI to report to a governmental official an adverse reaction that you may have to a medication.

5. When health oversight activities require disclosure. For example, I may have to provide information to assist the government in conducting an investigation or inspection of a health care provider or organization.

6. To avert a serious threat to health or safety. For example, I may have to use or disclose your PHI to avert a serious threat to the health or safety of others. Any such disclosures will only be made to someone able to prevent the threatening harm from occurring.

7. For specialized government functions. For example, I may have to use or disclose your PHI for national security purposes, including protecting the President of the United States or conducting intelligence operations, if you are in the military.

8. To remind you about appointments and to inform you of health-related benefits or services. For example, I may have to use or disclose your PHI to remind you about your appointments or to give you information about treatment alternatives, other health care services, or other health care benefits that I offer that may be of interest to you.

C. Certain Uses and Disclosures Require You to Have the Opportunity to Object.

Disclosures to family, friends, or others: I may provide your PHI to a family member, friend, or other person that you indicate that is involved in your care or the payment for your health care unless you object in whole or in part. The opportunity to consent may be obtained retroactively in an emergency situation.

D. Other Uses and Disclosures Require Your Prior Written Authorization. In any situation not described in sections III A, B, and C, above, I will need your written authorization before using or disclosing any of your PHI. If you choose to sign an authorization to disclose your PHI, you can later revoke such authorization in writing to stop any future uses and disclosures (to the extent that I have not taken any action in reliance on such authorization) of your PHI by me.


You have the following rights with respect to your PHI:

A. The Right to Request Restrictions on My Uses and Disclosures. You have the right to request restrictions or limitations on my uses or disclosures of your PHI to carry out my treatment, payment, or health care operations. You also have the right to request that I restrict or limit disclosures of your PHI to family members, friends, or others involved in your care or who are financially responsible for your care. Please submit such requests to me in writing. I will consider your requests but am not legally required to accept them. If I do accept your requests I will put them in writing and will abide by them except in emergency situations. Be advised that you may not limit the uses and disclosures that I am legally required to make.

B. The Right to Choose How I Send PHI to You. You have the right to request that I send confidential information to you at an alternate address (for example, sending information to your work address rather than your home address) or by alternate means (for example, e-mail instead of regular mail). I must agree to your request so long as it is reasonable and you specify how or where you wish to be contacted, and when appropriate, provide me with information as to how payment for such alternate communications will be handled. I may not require an explanation from you as to the basis of your request as a condition of providing communications on a confidential basis.

C. The Right to Inspect and Receive a Copy of Your PHI. In most cases, you have the right to inspect and receive a copy of the PHI that I have on you, but you must make the request to inspect and receive a copy of such information in writing. If I do not have your PHI but I know who does, I will tell you how to get it. I will respond to your request within 30 days of receiving your written request. In certain situations, I may deny your request. If I do, I will tell you, in writing, my reasons for the denial and explain your right to have my denial reviewed.

D. The Right to Receive a List of the Disclosures I Have Made. You have the right to receive an Accounting of Disclosure listing the instances in which I have disclosed your PHI. The list will not include disclosures made for my treatment, payment, or health care operations; disclosures made to you; disclosures you authorized; disclosures incident to a use; disclosures permitted or required by the federal privacy rule; disclosures made for national security or intelligence; disclosures made to correctional institutions or law enforcement personnel; and, disclosures made before April 14, 2003. I will respond to your request for an Accounting of Disclosure within 60 days of receiving such request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. The list will include the date the disclosure was made, to whom the PHI was disclosed (including their address, if known), a description of the information disclosed, and the reason for the disclosure. I will provide the list to you at no charge, but if you make more than one request in the same year I may charge you a reasonable, cost-based fee for each additional request.

E. The Right to Amend Your PHI. If you believe that there is a mistake in your PHI or that a piece of important information is missing, you have the right to request that I correct the existing information or add the missing information. You must provide, in writing, the request and your reason for the request. I will respond within 60 days of receiving your request to correct or update your PHI. I may deny your request in writing if the PHI is (i) correct and complete, (ii) not created by me, (iii) not allowed to be disclosed, or (iv) not part of my records. My written denial will state the reasons for the denial and explain your right to file a written statement of disagreement with the denial. If you do not file one, you have the right to request that your request and my denial be attached to all future disclosures of your PHI. If I approve your request to amend your PHI, I will make the changes, tell you that I have done it, and tell others that need to know about the change to your PHI.

F. The Right to Receive a Paper Copy of This Notice. You have the right to receive a paper copy of this notice even if you have agreed to receive it via email.


If you think that I may have violated your privacy rights, or you disagree with a decision I have made about access to your PHI, you may file a complaint with me. You may also send a written complaint to the Secretary of the Department of Health and Human Services at 200 Independence Avenue SW., Washington D. C. 20201. I will not take retaliatory action against you if you file a complaint about my privacy practices.


This Notice will go into effect on April 1, 2023. I reserve the right to change the terms of this notice. I will provide you with a revised notice as required.

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Electronic Communication Policy for Psychoeducational Group

Social Skills Group

In order to maintain clarity regarding our use of electronic modes of communication during your social skills group, I have prepared the following policy. The use of various types of electronic communication is common and many individuals prefer this method to communicate with others, whether it be for social or professional purposes. Many of these common modes of communication may put your privacy at risk and can be inconsistent with the law and with the standards of my profession. Consequently, this policy has been prepared to assure the security and confidentiality of your treatment and to assure that it is consistent with ethics and the law.

If you have any questions about this policy, please feel free to discuss this with me.

Email Communications
I use email communication and text messaging only with your permission and only for administrative purposes unless we have made another agreement. This means that email exchanges and text messages with my office should be limited to things like setting and changing appointments, billing matters and other related issues. Please do not email me about clinical matters as email is not a secure way to contact me. If you need to discuss a clinical matter with me, please feel free to call me at 949-221-4315. Telephone or face-to-face is a more secure mode of communication.

Social Media
I do not communicate with, or contact any of my clients through social media platforms like LinkedIn, Instagram or Facebook. Adding patients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. In addition, if I discover that I have accidentally established an online relationship with you, I will cancel that relationship. If you have questions about this policy, please bring this up when we meet so we can discuss it.

You may “like” The Child and Family Connection’s Facebook or Instagram business page. However, the information on my page is often on my website as well. If you “like” The Child and Family Connection’s page, you are choosing to reveal that you are connected to me in some way. My business page exists to be a forum of information and inspiration. I will not engage in conversations with you on that page. You are welcome to use your own discretion in choosing whether to follow my business page which may include business blogs and/or newsletters. Please note that I will not follow you back. If there are aspects from your online life that you wish to share, please bring them into your appointments where we can view and explore them together during our therapy sessions.

The Child and Family Connection has a website you are free to access. I use it to provide relevant information as it relates to social skills groups and psychotherapy. You are welcome to access and review the information that is on our website and if you have questions about it, please let me know.

Web Searches
I will not use web searches to gather information about you without your permission. I believe that this violates your privacy rights; however, I understand that you might choose to gather information about me in this way. At the present time, there is an incredible amount of information available about individuals on the internet, much of which may actually be known to that person and some of which may be inaccurate or unknown. If you encounter any information about me through web searches, or in any other fashion for that matter, please discuss this with me during our time together so that we can discuss it and its potential impact on social skills groups.

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