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 )
( Must be at least 12 years old )

( 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

Client Rights and Privacy


Sessions are scheduled on a regular basis 1 time weekly. Within the first month you will work with your clinician on developing a treatment plan. By the end of treatment you should be feeling better, and you should have learned some ways to help you continue to do your best.

At the final session, your clinician will be sure that you are prepared with any additional services you need after your treatment ends.  You may also be contacted a few months after treatment to find out if you are still doing well.


1)Respect-  You and your family will be treated with respect by clinician. 

2) Antidiscrimination- All individuals will be treated with dignity and respect. We do not discriminate on the basis of race, religion, national origin, age, gender or sexual orientation.

3)Freedom of Choice - At any time you have the right to: stop services

4)Confidentiality/ Privacy-Your information is private.  Your information will not be shared with anyone without your written consent.  (this includes parents if you are under the age of 18).    Information shared by a child may need to be shared with a parent, but is only done if the information is needed for treatment.

5)Access to Records-You have the right to read and have copies of your records in a timely manner. It may be required that a staff member be present to explain what is written. In the case that a client's record may hold information that could cause damage to the client to read, a summary may be provided in order to protect the client.

6)Freedom from Harm- Clinicians are mandated reporters and are required by law to report suspected and reported abuse, neglect and exploitation of children under the age of 18. If you need to report abuse, neglect and exploitation call the abuse hotline at 800 96 ABUSE  or 800 962 2873.

7)Complaints/Grievances- If you have a concern that is not resolved by speaking directly with your clinician, please contact the Heidi Chinlund, LCSW at (407) 625-0808 between the hours of 9am-5pm Monday through Friday, who will respond to your concern within three business days. 


Attendance    If you cannot keep an appointment, please call your clinician no later than 24 hours prior to your scheduled appointment time to cancel/reschedule. If you do not show or cancel three (3) appointments in a row, or within a 5 week period, it will result in an administrative discharge from services due to non-compliance.

Participation   Your participation is vital to the success of therapy. Your input will be needed in developing treatment plans.

Notification   Please keep your clinician informed of any of the following changes during treatment: address, phone, insurance.

Payment   You are responsible for any co-pays or deductibles as required by your insurance.


1)All clinicians will behave in a professional manner being: trustworthy, considerate and discrete.  

2)Consistent high quality treatment to you and your family.

3)Clinician is responsible for notifying you if they are running late or need to reschedule.

4)Purple Cactus Counseling, LLC will keep accurate records of provided treatment.

5)Purple Cactus Counseling, LLC has the right to cancel services if the client fails to follow through on the responsibilities listed above or if we believe that maximum benefit has been reached.

6)In the event that your services are terminated and you still need help, we will provide referrals for you.


1)Abuse and Neglect-  All Purple Cactus Counseling, LLC Staff are legally required to report all allegations or suspicions of abuse or neglect of children ages 0 to18 or elderly or disabled adults.

2)Danger to Self or others -If a client or family member is judged to be in danger of harming themselves or someone else, Purple Cactus Counseling, LLC Staff are required to protect that person or others from harm.  In some cases, hospitalization may be required.

3)Tobacco  Alcohol and Recreational Drugs-These are prohibited in our office or our office building.  Clients are not to use recreational drugs and alcohol prior to, or during sessions. If staff determines that a client in session is under the influence of alcohol or drugs, the staff  has the right to terminate the session. Purple Cactus Counseling, LLC Staff  are not to use tobacco products in the presence of client's or their families. 

 5) Weapons - Weapons of any kind are not permitted in Purple Cactus Counseling, LLC sessions.  During in-home sessions, all fire arms must be securely locked away.

( Type Full Name )
Purple Cactus Counseling, LLC Consent to Treatment

I acknowledge that I have received, have read (or have had read to me), and understand the "Client Rights and Privacy" brochure and/or other information about the therapy I am considering. I have had all my questions answered fully.

I hereby authorize and give consent to Purple Cactus Counseling, LLC and it's representatives to provide Counseling Services deemed necessary in my best interest, or in the interest of my child. I hereby indemnify and hold harmless Purple Cactus Counseling, LLC, the Service Provider (therapist/counselor), and other persons who act in reliance upon this authorization.

I do hereby seek and consent to take part in the treatment by Purple Cactus Counseling, LLC. I understand that developing a treatment plan with my therapist and regularly reviewing our work toward meeting the treatment goals are in my best interest. I agree to play an active role in this process.

I understand that no promises have been made to me as to the results of treatment or of any procedures provided by Purple Cactus Counseling, LLC.

I am aware that I may stop my treatment with my therapist at any time, or with Purple Cactus Counseling, LLC. I understand that I may lose other services or may have to deal with other problems if I stop treatment. (For example, if my treatment has been court-ordered, I will have to answer to the court.)

I know that I must call to cancel an appointment at least 24 hours (1 days) before the time of the appointment. If I cancel within 24 hours of my scheduled appointment a $25 fee will be charged to my card on file for insurance clients the $25 cancelation fee must be paid prior to scheduling next session.

 I understand that I will be eligible for discharge form services: when A) I have met all treatment plan objectives and goals; B) I request to be discharged from services; C) If there is no communication ( call, text, leave message, missed appointments, Face to face contact) between myself and therapist for three(3) consecutive weeks; or D) if there are three (3) consecutive cancellations/ no shows. I understand that my discharge, whether voluntary or involuntary allows me to resume services upon eligibility at any time in the future. 

I authorize Purple Cactus Counseling, LLC to submit billing to my insurance carrier for services received by me through Purple Cactus Counseling, LLC. I am aware that an agent of my insurance company or other third-party payer may be given information about the type(s), cost(s), date(s), and providers of any services or treatments I receive. I understand that if payment for the services I receive here is not made, the therapist may stop my treatment. For self-pay clients payment is due at beginning of each session.

This authorization shall remain in effect until conclusion of treatment for adults, or if authorization is made for a minor, until the minor's Eighteenth birthday unless sooner revoked in writing.

My signature below shows that I understand and agree with all of these statements.
( Type Full Name )
Limits of the Therapy Relationship: What Clients Should Know

Psychotherapy is a professional service I can provide to you. Because of the nature of therapy, our relationship has to be different from most relationships. It may differ in how long it lasts, in the topics we discuss, or in the goals of our relationship. It must also be limited to the relationship of therapist and client only. If we were to interact in any other ways, we would then have a "dual relationship," which would not be right and may not be legal. The different therapy professions have rules against such relationships to protect us both.

I want to explain why having a dual relationship is not a good idea. Dual relationships can set up conflicts between my own (the therapist's) interests and your (the client's) best interests, and then your interests might not be put first. In order to offer all my clients the best care, my judgment needs to be unselfish and professional.

Because I am your therapist, dual relationships like these are improper:      

 - I cannot be your supervisor, teacher, or evaluator.

 - I cannot be a therapist to my own relatives, friends (or the relatives of friends), people I know socially, or business contacts.

 - I cannot provide therapy to people I used to know socially, or to former business contacts.

 - I cannot have any other kind of business relationship with you besides the therapy itself. For example, I cannot employ you, lend to or borrow from you, or trade or barter your services (things like tutoring, repairing, child care, etc.) or goods for therapy.

 - I cannot give legal, medical, financial, or any other type of professional advice.

 - I cannot have any kind of romantic or sexual relationship with a former or current client, or any other people close to a client.

There are important differences between therapy and friendship. As your therapist, I cannot be your friend. Friends may see you only from their personal viewpoints and experiences. Friends may want to find quick and easy solutions to your problems so that they can feel helpful. These short-term solutions may not be in your long-term best interest. Friends do not usually follow up on their advice to see whether it was useful. They may need to have you do what they advise. A therapist offers you choices and helps you choose what is best for you. A therapist helps you learn how to solve problems better and make better decisions. A therapist's responses to your situation are based on tested theories and methods of change. You should also know that therapists are required to keep the identity of their clients secret. Therefore, I may ignore you when we meet in a public place, and I must decline to attend your family's gatherings if you invite me. Lastly, when our therapy is completed, I will not be able to be a friend to you like your other friends.

In sum, my duty as therapist is to care for you and my other clients, but only in the professional role of therapist. Please note any questions or concerns on the back of this page so we can discuss them
( Type Full Name )