Forms

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/

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GET IN TOUCH

CONTACT US REGARDING MORE INFORMATION ABOUT SERVICES WHICH WE PROVIDE.

Location

Availability

Evening hours and Saturday's by appointment only!

Call (304) 728-3527 for the most updated schedule

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To expedite your check-in process, please sign-in by scanning the QR CODE below with your phone and entering the required information: