Registration is only required if you do not have a username. Please check your spam & junk mail folders to ensure you have not already received an email with a username and password. If you already have a username log in here

Each account must have a unique email address associated with it. Please contact us if you need multiple accounts with the same email address (i.e. related family members).

Client Information

/ Middle Initial

( optional )


( for Text Message Reminders )

Bill To Contact

/ Middle Initial

Emergency Contact

First Name
Last Name

Log in Details

( If client is a minor, the legal guardian must enter their email address below. )

Between 8 and 40 letters and numbers

Challenge Questions

( These will be used to retrieve your password. Answers must be between 4 and 30 characters, cannot contain any spaces. )

( If you feel you must write down your questions in order to remember them, make sure to keep it in a safe place. )

Terms and Policy




We reserve the right to change this Notice of Privacy Practices and to make any new Notice of Privacy Practices effective for all protected health information that we maintain. Any new Notice of Privacy Practices adopted will be made available at your next appointment.


Protected health information ("PHI") is demographic and individually identifiable health information that will or may identify the patient and relates to the patient's past, present or future physical or mental health or condition and related health care services.


Under federal law, we are permitted to use and disclose personal health information without authorization for treatment, payment and health care operations.


Health care operations include activities such as communications among health care providers, conducting quality assessment and improvement activities; evaluating the qualifications, competence, and performance of health care professionals; training future health care professionals; other related services that may be a benefit to you such as case management and care coordination; contracting with insurance companies: conducting medical review and auditing services; compiling and analyzing information in anticipation of or for use in legal proceedings; and general administrative and business functions.


We use medical records as a way of recording health information, planning care and treatment and as a tool for routine health care operations. Your insurance company may request information such as procedure and diagnosis information that we are required to submit in order to bill for treatment we provide to the patient. Other health care providers or health plans reviewing your records must follow the same confidentiality laws and rules required of us.

Patient records are also a valuable tool used by researchers in finding the best possible treatment for diseases and medical conditions. All researchers must follow the same rules and laws that other health care providers are required to follow to ensure the privacy of patient information. Information that may identify patients will not be released for research purposes to anyone without written authorization from the patient or the patient's parent or legal guardian.

information released for any reason other than treatment, payment or healthcare operations.


Psychotherapy notes are notes recorded (in any medium) by a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session that are separated from the rest of the patient's medical record. Psychotherapy notes exclude medication prescription and monitoring, counseling session start and stop times, modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.


Psychosocial information is information provided regarding your social history and counseling or psychiatric services you have received before treatment with me.


In order to release patient protected health information for any reason other than treatment, payment and health care operations, we must have an authorization signed by the patient or the parent or guardian of the patient that clearly explains how they wish the information to be used and disclosed. The following are some examples of releases of information that require a separate authorization:

- Psychosocial information

- Use of information in scientific and educational publications, presentations and materials.


You may change your mind and revoke an authorization, except (1) to the extent that we have relied on the authorization up to that point, (2) the information is needed to maintain the integrity of the research study, or (3) if the authorization was obtained as a condition of obtaining insurance coverage. All requests to revoke an authorization should be in writing.


There are some services provided through contracts with business associates. Examples include billing services and transcription services. When these services are contracted, we may disclose your health information to the business associate so that they can perform the job we have contracted them to do.


The law requires that some information may be disclosed without your authorization in the following circumstances:

- In case of an emergency

- When there are communication or language barriers

- When required by law

- When there are risks to public health

- To conduct health oversight activities

- To report suspected child abuse or neglect or abuse/neglect to other disabled persons

- To specified government regulatory agencies

- In connection with judicial or administrative proceedings

- For law enforcement purposes

- To coroners, funeral directors, and for organ donation

- In the event of a serious threat to health or safety


The following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights.

1. You have the right to inspect and copy your health information.

This means you may inspect and obtain a copy of your PHI that is contained in a "designated record set" for so long as we maintain the PHI. A designated record set contains medical and billing records and any other records that we use in making decisions about your healthcare. You may not however, inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal or administrative action or proceeding, and certain PHI that is subject to laws that prohibit access to that PHI. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have the right to have this decision reviewed. Please contact our Privacy Officer if you have questions about access to your medical record.

2. You have the right to request a restriction of your health information.

This means you may ask us to restrict or limit the medical information we use or disclose for the purposes of treatment, payment or healthcare operations. We are not required to agree to a restriction that you may request. We will notify you if we deny your request. If we do agree to the requested restriction, we may not use or disclose your PHI in violation of that restriction unless it is needed to provide emergency treatment. You may request a restriction by contacting our Privacy Officer.

3. Your have the right to request to receive confidential communications by alternative means or at alternative locations.

We will accommodate reasonable requests. We may also condition this accommodation by asking you for an alternative address or other method of contact. We will not request an explanation from you as the basis for the request. Requests must be made in writing to our Privacy Officer.

4. You have the right to request amendments to your health information.

This means you may request an amendment of PHI about you in a designated record set for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request, you have the right to file a statement of disagreement with our Privacy Office and we may prepare a rebuttal to your statement and will provide you with a copy of this rebuttal. If you wish to amend your PHI, please contact our Privacy Officer. Requests for amendment must be in writing.

5. You have the right to receive an accounting of disclosures of your health information.

You have the right to request an accounting of certain disclosures of your PHI. This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Privacy Notice. We are also not required to account for disclosures that you requested, disclosures that you agreed to by signing an authorization form, to family or friends involved in your care, or certain other disclosures we are permitted to make without your authorization. The request for an accounting must be made in writing to our Privacy Officer. The request should specify the time period sought for the accounting. Accounting requests may not be made for periods of time in excess of six years.

6. You have the right to receive a paper copy of this Notice of Privacy Practices.


If you have questions regarding your privacy rights or if you believe your privacy rights have been violated, please contact Heather Harris, LMHC, or with the Secretary of the Department of Health and Human Services. You will not be penalized for filing a complaint. The address for the Secretary of the Department of Health and Human Services is:

Office of Civil Rights

U.S. Department of Health and Human Services

Atlanta Federal Center

Suite 3B70

61 Forsyth St., S.W.

Atlanta, GA 30303-8909

(404) 562-7886 (phone)

(404) 562-7881 (fax)

(404) 331-2867 (TDD)

I have read the above notice of privacy practice and I understand I am able to print this document if I wish to have a paper copy of the privacy practices. 

( Type Full Name )
Hope Counseling Solutions Private Practice Social Media Policy
Private Practice Social Media Policy

This document outlines Hope Counseling Solutions policies related to use of Social Media. Please read it to understand how we conduct ourselves on the Internet as a mental health professional and how you can expect us to respond to various interactions that may occur between us on the Internet. If you have any questions about anything within this document, we encourage you to bring them up when we meet. As new technology develops and the Internet changes, there may be times when we need to update this policy. Such updates will be made available to you on our website.


We do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc). We believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when we meet and we can talk more about it.


We may keep a Facebook Page for professional practice to allow people to share blog posts and practice updates with other Facebook users. You are welcome to view our Facebook Page and read or share articles posted there, but we do not accept clients as Fans of this Page. We believe having clients as Facebook Fans creates a greater likelihood of compromised client confidentiality and we feel it is best to be explicit to all who may view our list of Fans to know that they will not find client names on that list. Note that you should be able to subscribe to the page via RSS without becoming a Fan and without creating a visible, public link to my Page. You are more than welcome to do this.


We may publish a blog on our website or elsewhere online. We may use other social media sites to share information related to our professional field and practice. We have no expectation that you as a client will want to follow our blog or postings. However, if you use an easily recognizable name on such an account and we happen to notice that you've followed us there, we may briefly discuss it and its potential impact on our working relationship. Our primary concern is your privacy. If you share this concern, there are more private ways to follow me online(such as using an RSS feed or a locked Twitter list), which would eliminate your having a public link to our content. You are welcome to use your own discretion in choosing whether to follow us. Note that we will not follow you back. Our reasoning is that we believe casual viewing of clients' online content outside of the therapy hour can create confusion in regard to whether it's being done as a part of your treatment or to satisfy our personal curiosity. In addition, viewing your online activities without your consent and without our explicit arrangement towards a specific purpose could potentially have a negative influence on our working relationship. If there are things from your online life that you wish to share with us, please bring them into our sessions where we can view and explore them together, during the therapy appointment.


Please do not use texting or messaging on Social Networking sites such as Twitter, Facebook, or LinkedIn to contact us. These sites are not secure and we may not read these messages in a timely fashion. Do not use Wall postings, @replies, or other means of engaging with us in public online if we have an already established client/therapist relationship. Engaging with us this way could compromise your confidentiality. It may also create the possibility that these exchanges become a part of your legal medical record and will need to be documented and archived in your chart. If you need to contact us between sessions, the best way to do so is through the secure client area on our website.


It is NOT a regular part of our practice to search for clients on Google or Facebook or other search engines. Extremely rare exceptions may be made during times of crisis. If we have a reason to suspect that you are in danger and you have not been in touch with us via our usual means (coming to appointments, phone, or email) there might be an instance in which using a search engine (to find you, find someone close to you, or to check on your recent status updates / check-ins) becomes necessary as part of ensuring your welfare. These are unusual situations and if we ever resort to such means, we will fully document it and discuss it with you when we next meet. Such searches would be used only as a last resort after exhausting other known options, including your emergency contact person.


You may find our practice on sites such as Yelp, Healthgrades, Yahoo Local, Bing, or other places which list businesses. Some of these sites include forums in which users rate their providers and add reviews. Many of these sites comb search engines for business listings and automatically add listings regardless of whether the business has added itself to the site. If you should find our listing on any of these sites, please know that our listing is NOT a request for a testimonial, rating, or endorsement from you as our client. Of course, you have a right to express yourself on any site you wish. But due to confidentiality, we cannot respond to any review on any of these sites whether it is positive or negative. We urge you to take your own privacy as seriously as we take our commitment of confidentiality to you. You should also be aware that if you are using these sites to communicate indirectly with us about your feelings about our work, there is a good possibility that we may never see it. If we are working together, we hope that you will bring your feelings and reactions to our work directly into the therapy process. This can be an important part of therapy, even if you decide we are not a good fit. None of this is meant to keep you from sharing that you are in therapy with us wherever and with whomever you like. Confidentiality means that we cannot tell people that you are our client and my Ethics Code prohibits me from requesting testimonials. But you are more than welcome to tell anyone you wish that we provide your therapy or how you feel about the treatment we provided to you, in any forum of your choosing. If you do choose to write something on a business review site, we hope you will keep in mind that you may be sharing personally revealing information in a public forum. We urge you to create a pseudonym that is not linked to your regular email address or friend networks for your own privacy and protection. If you feel we have done something harmful or unethical and you do not feel comfortable discussing it with us, you can always contact the US Department of Health and Human Services 200 Independence Avenue S.W., Washington, D.C. 20201.


If you used location-based services on your mobile phone, you may wish to be aware of the privacy issues related to using these services. We do not place our practice as a check-in location on various sites such as Foursquare, Gowalla, Loopt, etc. However, if you have GPS tracking enabled on your device, it is possible that others may surmise that you are a therapy client due to regular check-ins at our office on a weekly basis. Please be aware of this risk if you are intentionally "checking in," from our office or if you have a passive LBS app enabled on your phone.


Please be aware that if you email content related to your therapy sessions, email is not completely secure or confidential. If you choose to communicate with us by email, be aware that all emails are retained in the logs of your and our Internet service providers. While it is unlikely that someone will be looking at these logs, they are, in theory, available to be read by the system administrator(s) of the Internet service provider. You should also know that any emails received from you and any responses that we send to you become a part of your legal record. You can email us securely by logging into your account on the patient login link to the electronic medical record system on our webpage.


Thank you for taking the time to review our Social Media Policy. If you have questions or concerns about any of these policies and procedures or regarding our potential interactions on the Internet, do bring them to our attention so that we can discuss them.

In summary, if you wish to contact us, please call the office at (317) 961-8366 or email us at Any other attempts to contact us online or via texting will receive no response. Thank you.

****This form's original author is Keely Kolmes, Psy.D. It has been modified to address specific matters related to Hope Counseling Solutions.***

( Type Full Name )