Phone Counseling Appointment
Name (First)
Name (Last)
Address
City and State
Zip Code
Phone
Email
STEP # 2: Fill out Two Forms:
Telemedicine Informed Consent
FAX : 724-327-7900
Dr. Lynne Logan
4889 William Penn Highway
P.O. Box # 330
Murrysville, PA 15668-2008
FORM # 1
Counseling Intake Form
FORM # 2
You may Fax or Mail your forms back >>>>
STEP # 3: By Checking the Agreement Boxes Below, I Agree:
I have read and understand the Telemedicine
Consent Form and agree to it's terms.
I agree to return the Phone Counseling Intake
Form and Telemedicine Consent form within 72
hours of my appointment (Faxed or Mail)
I have Paid for Services by Pay Pal. I understand
my credit card information will go directly to
Pay Pal and not to Dr. Lynne Logan
I am 18 years of age or older.
I am not having suicidal or homocidal thoughts.
I understand if I cancel my apppointment less
than 24 hours, I will be charged.
Additional Comments or Questions:
If you have scheduled a Phone Counseling Appointment with Dr.
Lynne, you are now ready to do the following easy steps:

STEP #1: Fill in the following Information Form:
Asking for Help
is a
Sign of Strength;
For a Broken Heart,
or a Wounded Soul,
the
Sooner You Heal,
the Sooner You'll Smile.
Phone Counseling Appointment
Solution Graphics
Call Toll Free:
1-877-CALL-197
Choose Amount of Time
STEP # 4 FINAL STEP: Pay for Service through Pay Pal:
Hope
for a
Better Future
is
Taking One Step
When You Can't
See the Whole Staircase.