General Intake 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.


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

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

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

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

Graduated Sanctions – Probation/Parole:  https://jeffersondrc.wufoo.com/forms/z1fi56cp1bw8eeq/

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

Telemedicine Informed Consent Form (GI): https://jeffersondrc.wufoo.com/forms/q18bsxuz0ycc1l8/

Patient Insurance Information Form (GI):  https://jeffersondrc.wufoo.com/forms/q1t555p31pu4qy1/

Consent for Disclosure of Confidential (GI):  https://jeffersondrc.wufoo.com/forms/q2fct3a1vtuvtn/

Limits of Confidentiality (GI):  https://jeffersondrc.wufoo.com/forms/q12stx640u2uxxg/

Behavioral Health Screen (GI): https://www.surveymonkey.com/r/25LFKKR

Tobacco Screen (GI): https://www.surveymonkey.com/r/CKY6YRD

Consent for Disclosure (GI): https://jeffersondrc.wufoo.com/forms/r18gfzie0mjnah4/

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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!

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