(1)  Medical Form

You must enter in your name and email address in the appropriate fields. Additionally, please collect the following information and enter it in to the Medical Form:

• List of medications, including dosage, side effects, restrictions, schedule, and for what condition
• Immunization records, including year administered
• Dates of significant injuries and illnesses
• Primary Physician contact information
• Health Insurance information (Policy Number, Group Number, Policy Holder, etc.)

(2)  disclosure and confidentiality agreement

Please be sure to read this information to ensure that you are familiar with the contents. When you are finished reading, you must sign in the indicated areas. 

(3)  RISK ACKNOWLEDGEMENT

Please read the Risk Acknowledgment carefully! When you are finished reading, you must sign in the indicated areas. You will receive another signature validation email, and request for confirmation.

(4)  Mental Health Screening Assessment

Please read and complete the Mental Health Screen Assessment according to the directions given by the link below.

(4)  What’s next?

Within three to five business days you will receive a follow up call with a representative from LOGOS. If you have any questions or concerns in the meantime, please contact Chelsea Van Essen at chelsea@logoswildernesstherapy.org.