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