Phone Counseling
    Appointment
Name (First)
Name (Last)
Address
City and State
Zip Code
Phone
Email
STEP # 2: For Phone Appt. ONLY. Fill out Two Forms:
Telemedicine Informed Consent
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 Counseling Intake Form and
Telemedicine Informed Consent (phone appointment
only) within 72 hours of making my appointment
(Faxed or Mail)
I will pay for Services by Pay Pal. I understand
my credit card information will go directly to
Pay Pal
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.
The Send Button will take you to your Confirmation and Payment Page
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 Information Form:
Solution Graphics
Lynne Logan Ph.D., M.F.T.
Serving Orange County
The Medical Center
500 S. Anaheim Hills Road, Suite 202
Anaheim Hills, CA. 92807
Call 714-883-9722
Lynne Logan Ph.D., M.F.T.
Serving Orange County
The Medical Center
500 S. Anaheim Hills Road, Suite 202
Anaheim Hills, CA. 92807
Call 714-883-9722
EMAIL: drlynnelogan@yahoo.com
 Phone Counseling
    Appointment
Hope
for a
Better Future
is
Taking One Step
At a Time
When You Can't
See the Whole
Staircase.
Acceptance Mark