Informed Consent & Disclosure Agreement
California Licensed Marriage and Family Therapist (LMFT)
Confidential Client Document — Please read carefully and ask any questions before signing.
1. Counselor Information
Counselor name: Barbara Rorbach
Professional title: Licensed Marriage and Family Therapist (LMFT)
California license number: LMFT #145429
Practice name: Rorbach Counseling
Business address: Klingele-Haus 1. OG, Kehrstrasse 12, 3904 Naters
Telephone: +41 77 462 78 65 Email: barbara@rorbachcounseling.com
2. Purpose and Nature of Counseling
Counseling is a collaborative professional relationship intended to help clients understand their emotions, thoughts, behaviors, relationships, and life experiences. Treatment may address concerns such as anxiety, depression, trauma, grief, relationship difficulties, family conflict, communication challenges, life transitions, and other psychological or interpersonal concerns within the therapist’s scope of practice.
Treatment may involve assessment, discussion of personal experiences, emotional processing, exploration of relationship patterns, therapeutic exercises, skills development, and other appropriate interventions.
The counselor will discuss treatment goals and the proposed approach with the client and review progress as appropriate.
3. Potential Benefits and Risks
Potential benefits may include improved emotional awareness, coping skills, communication, relationship functioning, and psychological well-being. Outcomes vary, and specific results cannot be guaranteed.
Counseling may also involve temporary or ongoing discomfort. Clients may experience difficult emotions, anxiety, sadness, anger, uncertainty, or distress when exploring painful experiences or discussing sensitive relationship issues. Changes in relationships or personal circumstances may occur as clients gain insight and make decisions.
The counselor will work collaboratively with clients to monitor their responses and adjust treatment when appropriate.
4. Voluntary Participation and Client Rights
Participation in counseling is voluntary
Clients have the right to:
Receive understandable information about the proposed treatment.
Ask questions about methods, professional qualifications, and treatment recommendations.
Participate in developing and reviewing treatment goals.
Express concerns or request clarification about the process.
Discuss reasonable alternatives, including referral to another provider when appropriate.
Decline a proposed intervention or withdraw consent, subject to applicable law and any legal obligations.
Receive respectful, professional, and nondiscriminatory care.
Raise concerns about the services provided.
Clients are encouraged to communicate openly about their needs, expectations, and concerns.
5. Confidentiality and Its Limits
Information shared during counseling is generally confidential and will be protected.
However, confidentiality is not absolute. Depending on the circumstances, the counselor may be required or permitted to disclose information without the client's authorization, including situations involving:
Suspected child abuse or neglect requiring a report under applicable law.
Suspected abuse of an elder or dependent adult requiring a report under applicable law.
Certain serious threats of harm to another person or circumstances involving a duty to protect or warn, as applicable.
A serious risk of harm to the client when disclosure or intervention is legally authorized or required.
A valid court order or other legally enforceable process, subject to applicable protections and objections.
Other disclosures specifically authorized or required by law.
The counselor will disclose only information reasonably necessary for the applicable purpose, consistent with legal obligations.
The counselor will explain relevant confidentiality questions and limitations as they arise. Clients may ask questions about privacy and the handling of their records at any time.
6. Couples Counseling
When services involve couples, the counselor will clarify who the identified client or clients are, the purpose of treatment, and the applicable confidentiality and information-sharing arrangements.
Participants understand that information shared in joint sessions may be heard by the other participants. The counselor cannot guarantee that other participants will keep information confidential outside sessions.
Policy regarding individual disclosures during couples counseling:
Couples counseling relies on honesty, openness, and trust. This practice follows a No Secrets Policy to support the therapeutic process and the goals of treatment.
Information disclosed privately by either partner that is materially relevant to couples counseling will not be promised confidentiality from the other partner. The counselor will generally encourage the disclosing partner to share the information directly, with support when appropriate.
If a partner is unwilling to disclose information essential to the therapeutic process, the counselor may pause or discontinue couples counseling or recommend an alternative treatment arrangement.
7. Treatment Methods and Professional Boundaries
The counselor will use clinically appropriate methods consistent with professional competence and the needs of the client. The counselor may recommend consultation, additional evaluation, or referral when appropriate.
Counseling is not a guarantee of a particular outcome and does not replace medical care or other specialized services when those services are needed.
The counseling relationship is professional. Romantic or sexual relationships with current clients are prohibited. Clients are encouraged to communicate any concerns about boundaries or the therapeutic relationship.
8. Appointments, Fees, and Payment,
Standard session length: 50 minutes
Individual session fee: CHF 150
Couples session fee: CHF 180, CHF 250 (for 90 min session)
Payment methods: Debit/Credit Card, online payment
Payment is due the day of the session.
10. Appointment Cancellation, Rescheduling, and Missed Sessions
A minimum of 24 hours' notice is required to cancel or reschedule an appointment.
Cancellations or rescheduling requests made less than 24 hours before the scheduled appointment may be charged the full session fee.
Missed appointments and no-shows: If a client fails to attend a scheduled appointment without providing the required 24-hour notice, the client is responsible for payment of the full scheduled session fee.
Exceptions may be considered at the therapist's discretion in circumstances involving emergencies or other extraordinary situations.
By signing this agreement, the client acknowledges and agrees to this cancellation and missed-appointment policy.
10. Telehealth Services
Telehealth involves receiving counseling through electronic communication, such as secure video or other approved communication technologies.
Potential benefits include convenience, accessibility, and continuity of care. Potential risks include technology failure, interruptions, reduced ability to observe certain nonverbal cues, privacy risks, and limitations in responding to emergencies.
Clients agree to take reasonable steps to participate from a private location using an appropriate device and connection. The counselor will take reasonable measures to protect confidentiality and determine whether telehealth is clinically appropriate.
11. Emergencies and Crisis Support
Counseling appointments and electronic messages are not emergency services. The counselor cannot guarantee immediate availability outside scheduled sessions.
In case of a medical emergency, please dial 144.
Are you a victim of domestic violence? Please dial 142.
If you are in psychological distress and/or have suicidal thoughts, please dial 143.
Clients are encouraged to discuss safety concerns promptly and to develop an appropriate crisis plan when clinically indicated.
12. Communication and Electronic Messaging
The therapist may communicate with clients through approved methods such as telephone, secure client portals, or email, as agreed upon.
Electronic communications may carry privacy risks. Routine electronic messages should not be used for urgent or emergency matters.
Approved communication methods: phone, e-mail
Clients should avoid sending unnecessary sensitive information through unsecured communication channels.
13. Ending Treatment
Clients may discuss ending counseling at any time. When clinically appropriate, the counselor may recommend a planned termination process to review progress, discuss continuing needs, and identify additional support.
The counselor may recommend transfer or referral when services fall outside the counselor’s competence, when treatment is no longer appropriate, or when other professional considerations warrant it.
15. Client Acknowledgment and Consent
By signing below, I acknowledge that:
I have read this document, or it has been explained to me in a language I understand.
I have had an opportunity to ask questions and receive answers about the nature and purpose of counseling.
I understand the potential benefits and risks of treatment and that outcomes cannot be guaranteed.
I understand the general limits of confidentiality and the circumstances in which disclosure may be required or permitted by law.
I understand the applicable fees, payment arrangements, and cancellation policy.
If telehealth is used, I understand its relevant risks and limitations and have provided the required consent.
I understand that I may discuss concerns, treatment alternatives, and withdrawal of consent with the counselor.
I voluntarily consent to participate in counseling under the terms explained in this agreement.