INFORMED CONSENT FOR PSYCHOTHERAPY

Natalie McBroom, LMFT
Licensed Marriage and Family Therapist

• California: LMFT LIC #106122
• Arizona: LMFT LIC #LMFT-15874
• Montana: LMFT LIC #BBH-LMFT-LIC-50724

Office Address: 251 West Main Street, Suite M, Brawley, CA 92227
Mailing Address: P.O. Box 875, Brawley, CA 92227
Practice Phone: 760-550-1745
Document Updated: September 22, 2026

GENERAL INFORMATION

The therapeutic relationship is unique in that it is highly personal and, at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work and what each of us can expect. This consent provides a clear framework for our clinical work together. Feel free to discuss any of these parameters with me at any time. Please read this document thoroughly and indicate your agreement by checking the box at the conclusion of this form.

THE THERAPEUTIC PROCESS & CLINICAL PACING

Deciding to seek psychotherapy is a positive step toward personal growth. The outcome of your treatment depends largely on your willingness to actively engage in this process, which may, at times, result in considerable emotional discomfort. Remembering unpleasant life events and becoming aware of deeply rooted feelings can temporarily bring about strong feelings of anger, depression, or acute anxiety.

There are no definitive medical cures or guarantees in psychotherapy. I cannot promise that your behavior or immediate circumstances will change. I do pledge to support you, utilize my clinical training to help you clarify what you want for yourself, and guide you in identifying and safely shifting self-sabotaging patterns. Standard individual clinical sessions are structured as 53+ minute blocks.

RISKS AND BENEFITS OF THERAPY

Psychotherapy is a collaborative effort between the client and the therapist designed to create positive change so you can experience life more fully. Participating in therapy may result in a number of long-term benefits, including reduced stress, increased interpersonal capacity, improved boundaries, a decrease in negative thoughts, and heightened self-confidence.

However, personal growth requires substantial vulnerability. There may be times when your perceptions or core assumptions are actively challenged. The issues addressed in session may result in unintended outcomes, including changes in personal or marital relationships. Any decisions regarding the status of your relationships remain entirely your personal responsibility. During the course of treatment, many individuals find that they temporarily feel worse before they feel better. Personal growth can be non-linear, slow, and frustrating at times; you are always encouraged to address progress concerns openly during your sessions.

TELEHEALTH & IN-OFFICE MODALITY RULES

This practice offers both in-person clinical services and secure online tele-behavioral video health. Clients must understand and agree to the guidelines governing these separate clinical modalities:

1. Telehealth Jurisdictional Constraints: Due to strict state licensing laws, I am legally permitted to provide telehealth therapy sessions only to individuals who are physically located within the state lines of California, Arizona, or Montana at the exact time of service. If you cross state lines or temporarily travel outside of these three states, professional clinical sessions cannot proceed.
2. Crisis Limitations: Online telehealth services are not designed or equipped for acute psychiatric crises or urgent emergency needs. If you are experiencing a severe mental health crisis, you agree to utilize the localized or national crisis emergency lines detailed below rather than relying on telehealth portals.
3. Documentation Restrictions: I do not provide legal documentation for courts, formal return-to-work reports, worker's compensation requests, disability claims, or SSI attestation services when clinical treatments are rendered via an online video modality. If you require deep, court-mandated assessments or character attestations, you will be referred out to a specialist trained to meet those forensic parameters.
4. Technology & Clinical Risks: By engaging in online counseling, you acknowledge the inherent risks, including occasional technological disruptions, connectivity lapses, and the limitations placed on the therapist's ability to observe direct non-verbal, visual, or physical cues.

Natalie McBroom’s office telephone, voicemail, email, text messaging, and client portal are not continuously monitored and should not be used to obtain emergency or crisis assistance. Natalie McBroom, LMFT, does not provide 24-hour crisis response or emergency services.

If you are in immediate danger, have taken steps to harm yourself or another person, or believe that you cannot remain safe, call 911 or go to the nearest hospital emergency department. If you are experiencing suicidal thoughts, severe emotional distress, or another behavioral-health crisis but are not in immediate physical danger, call or text 988 or contact an appropriate crisis resource listed below.

• Emergency Services: Call 911 or go to the nearest hospital emergency department if you or another person is in immediate danger.
• 988 Suicide & Crisis Lifeline: Call or text 988 for free and confidential crisis support available 24 hours a day, seven days a week throughout the United States.
• Crisis Text Line: Text HOME to 741741 to communicate with a trained crisis counselor 24 hours a day, seven days a week.
• Veterans Crisis Line: Call 988 and press 1, or text 838255.
• National Domestic Violence Hotline: Call 1-800-799-SAFE (7233) or text START to 88788.
• National Sexual Assault Hotline (RAINN): Call 1-800-656-HOPE (4673).
• SAMHSA National Helpline: Call 1-800-662-HELP (4357) for confidential mental-health and substance-use treatment information and referrals.

• Imperial County Behavioral Health Crisis Line: Call 1-800-817-5292 for urgent behavioral-health support. The crisis line is available 24 hours a day, seven days a week. (bhs.imperialcounty.org)
• Imperial County Behavioral Health Services Access Line: Call (442) 265-1525, Monday through Friday, from 8:00 a.m. to 5:00 p.m., for information about behavioral-health services. This number is not a substitute for 911, 988, or the 24-hour crisis line. (Behavioral Health Services)
• Imperial County Behavioral Health Services: 202 N. Eighth Street, El Centro, CA 92243. Call before going to this location to confirm that it is the appropriate location for the services needed. (Behavioral Health Services)
• Center for Family Solutions: Call (760) 353-8530 for community support related to domestic violence, sexual assault, safety planning, and related concerns.
• Imperial County Child Protective Services: Call (760) 337-7750 to report suspected child abuse or neglect. If a child is in immediate danger, call 911.
• SURE 24-Hour Helpline: Call (760) 352-7873.
• Imperial County Rape Crisis Center: Call (760) 352-7273.
• California 211: Dial 211 for information and referrals concerning local health care, mental-health services, housing, food, utilities, employment assistance, and other community resources. Availability and hours may vary by county. (cpuc.ca.gov)

Imperial County Behavioral Health Services currently publishes the Center for Family Solutions, CPS, SURE Helpline, and Rape Crisis Center numbers as emergency and community resources. (bhs.imperialcounty.org)

• Montana Suicide Prevention and Mental Health Crisis Lifeline: Call or text 988. Montana calls are routed to participating crisis centers within the state. (dphhs.mt.gov)
• Montana Warm Line: Call 1-877-688-3377 for non-emergency peer support related to anxiety, depression, loneliness, stress, grief and loss, substance use, bullying, or supporting another person. The Warm Line is not a substitute for 911 or 988 during an emergency. (dphhs.mt.gov)
• Montana 211: Dial 211 for information and referrals concerning local health and human services, housing, food, transportation, financial assistance, and other community resources. (map.mt.gov)
• Montana Child Abuse and Neglect Hotline: Call 1-866-820-5437 to report suspected child abuse or neglect. This toll-free hotline is available 24 hours a day. If a child is in immediate danger, call 911. (dphhs.mt.gov)
• Montana Adult Protective Services: Call 1-844-277-9300 to report suspected abuse, neglect, exploitation, or self-neglect involving an older person or an adult with a disability. Telephone offices are generally available Monday through Friday from 8:00 a.m. to 5:00 p.m., excluding holidays. If someone is in immediate danger, call 911. (dphhs.mt.gov)

• Arizona Statewide Crisis Hotline: Call 1-844-534-HOPE (4673) or text HOPE to 4HOPE (44673). Crisis services are available to Arizona residents regardless of health-insurance coverage. (www.azahcccs.gov)
• Arizona 211: Dial 211 for information and referrals concerning local health care, mental-health services, housing, food, transportation, domestic-violence services, financial assistance, and other community resources.
• Arizona Child Abuse Hotline: Call 1-888-SOS-CHILD (1-888-767-2445) to report suspected child abuse or neglect. The hotline is available 24 hours a day, seven days a week. If a child is in immediate danger, call 911. (dcs.az.gov)
• Arizona Adult Protective Services: Call 1-877-SOS-ADULT (1-877-767-2385) to report suspected abuse, neglect, exploitation, or self-neglect involving a vulnerable adult. Online reporting is also available through Arizona Adult Protective Services. If someone is in immediate danger, call 911. (des.az.gov)

The organizations and resources listed above are independent of Natalie McBroom, LMFT. Their inclusion in this document does not constitute an endorsement, referral agreement, or guarantee that services will be available or appropriate for a particular person or situation.

Telephone numbers, operating hours, eligibility requirements, service areas, and availability may change without notice. Clients are responsible for contacting the organization directly to confirm current information. When immediate safety is uncertain, call 911 or 988.

Contacting a crisis line does not guarantee that emergency intervention, hospitalization, mobile crisis response, or another particular service will or will not occur. Crisis personnel will evaluate the circumstances and determine an appropriate response according to their own policies and procedures.

Clients are encouraged to discuss suicidal thoughts, self-harm urges, violent thoughts, safety concerns, or worsening symptoms with Natalie during scheduled sessions. Disclosure of such thoughts does not automatically result in hospitalization or law-enforcement involvement. Natalie will assess the nature and immediacy of the risk and work collaboratively with the client whenever clinically and legally appropriate. However, when Natalie reasonably believes that a client or another identifiable person faces a serious and imminent threat, she may take protective action as permitted or required by applicable law and professional ethics.

Because informed-consent and duty-to-protect requirements differ among California, Montana, and Arizona, this section should be reviewed alongside your separate provisions addressing confidentiality exceptions, mandated reporting, professional availability, telehealth emergencies, and duty to protect. A review by your professional liability carrier or a health-care attorney licensed in the relevant jurisdictions would also be prudent.

PRIVILEGE OF CONFIDENTIALITY & LEGAL LIMITATIONS

All session content, clinical documentation, and billing files will be held strictly confidential in accordance with HIPAA regulations and state rules. Information will not be released to third parties without your explicit, signed written authorization. If you participate in marital or family therapy, confidential records will not be disclosed to external entities unless all adult participants who engaged in the treatment provide independent written authorization to release.

By state and federal law, the therapist's mandate to protect client confidentiality is legally overridden, and information must be disclosed under the following exceptional circumstances:

1. Clear evidence exists that a client intends or attempts to commit suicide, or exhibits behavior presenting a substantial, immediate risk of serious self-inflicted bodily harm.
2. A client communicates a grave, explicit threat of bodily harm or imminent death directed toward an identifiable target person.
3. The therapist develops a reasonable suspicion that a child under the age of 18, an elderly person (65+), or a dependent adult is being subjected to, or is an observer of, active physical abuse, emotional abuse, sexual abuse, or systemic physical neglect.
4. A court of law issues a legally binding court order or judicial subpoena signed by a judge.
5. In compliance with federal provisions under the Patriot Act of 2001, the practice may be legally required to provide federal agents with specified operational records under a national security warrant, which explicitly prohibits the therapist from notifying the client that such a search has occurred.

ADMINISTRATIVE CONSULTATION

To ensure the highest standard of care, I occasionally consult with other licensed clinical specialists regarding therapeutic strategies or diagnostic evaluations. During these professional consultations, your identity is completely protected, your name is never disclosed, and your information is shared strictly using anonymized clinical summaries.

Licensed Marriage and Family Therapist

Updated 09/22/2026 by Natalie McBroom, LMFT