General Intake Packet (You must complete all forms included in this section.)

Please contact the office at (304) 728-3527 if you need assistance.

General Intake Demographic:  https://jeffersondrc.wufoo.com/forms/z1096hd31buawf5/

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

Confidentiality Agreement for Day Report Clients:  https://jeffersondrc.wufoo.com/forms/p12kjma40l17m9w/

Consent for Disclosure of Confidential SA/MH:  https://jeffersondrc.wufoo.com/forms/k1dtgp4x15n5e6o/

Graduated Sanctions:  https://jeffersondrc.wufoo.com/forms/z1fi56cp1bw8eeq/  

Telemedicine Consent:  https://jeffersondrc.wufoo.com/forms/zjli3qf14bw9ek/

Call-in Testing:  https://jeffersondrc.wufoo.com/forms/zkx9rql048da87/

Consent to Bill:    https://jeffersondrc.wufoo.com/forms/zo373ip15eb8s6/

Treatment Disclosure:  https://jeffersondrc.wufoo.com/forms/z1mw50p814unzbo/

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