DUI Intake Forms

You must complete all forms included in this section. Please contact the office at (304) 728-3527 if you need assistance.


Intake (DUI):  https://jeffersondrc.wufoo.com/forms/m1oewivi18qmr6h/

Agreement of Understanding Form (DUI): https://jeffersondrc.wufoo.com/forms/mry7jli0ap14yr/

Client Rights and Responsibilities (DUI): https://jeffersondrc.wufoo.com/forms/mtq9pna1yjd22w/

Authorization for Release and/or Exchange (DUI):  https://jeffersondrc.wufoo.com/forms/m5oind41y067pl/

Consent for Disclosure of Confidential (DUI):  https://jeffersondrc.wufoo.com/forms/k1dtgp4x15n5e6o/

Telemedicine Informed Consent Form (DUI):  https://jeffersondrc.wufoo.com/forms/zjli3qf14bw9ek/

Limits of Confidentiality (DUI):  https://jeffersondrc.wufoo.com/forms/z1t63uia0o6gw0u/

Levels Acknowledgement (DUI):  https://jeffersondrc.wufoo.com/forms/mz4ro0q1rv5fn5/

Client Handbook (DUI): https://jeffersondrc.wufoo.com/forms/r1ta4ryi04k7zry/

West Virginia DMV DUI Safety and Treatment Program (WV RESIDENTS ONLY)https://jeffersondrc.wufoo.com/forms/m1atsutw0msjnhd/

DAST (DUI): https://www.surveymonkey.com/r/G76FNWV

AUDIT (DUI): https://www.surveymonkey.com/r/BFK923V

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