DUI Intake Forms

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/

Patient Insurance Information Form (DUI):  https://jeffersondrc.wufoo.com/forms/m1nw5spr1oxc5yy/

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/

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

Alcohol Screening Questionnaire (DUI): https://www.surveymonkey.com/r/HLTZ6KY

Drug Abuse Screening Test (DUI):  https://www.surveymonkey.com/r/HLV9L3H

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CONTACT US REGARDING MORE INFORMATION ABOUT SERVICES WHICH WE PROVIDE.

Location

Availability

Evening hours and Saturday's by appointment only!

Monday:

9:00 am-9:00 pm

Tuesday:

9:00 am-9:00 pm

Wednesday:

9:00 am-7:00 pm

Thursday:

9:00 am-5:00 pm

Friday:

9:00 am-5:00 pm

Saturday:

9:00 am-3:00 pm

Sunday:

Closed