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/ql6d671ngotsd/
Confidentiality Agreement for DRC Clients: https://jeffersondrc.wufoo.com/forms/q1ew3c3p03gilys/
Consent for Disclosure: https://jeffersondrc.wufoo.com/forms/q194i6fv1arw906/
Limits of Confidentiality: https://jeffersondrc.wufoo.com/forms/q1jt0r6x1jadppl/
Patient Insurance Information Form: https://jeffersondrc.wufoo.com/forms/q1m0gm6a0clgv73/
Telemedicine Informed Consent Form: https://jeffersondrc.wufoo.com/forms/r161qnmo1euihp6/
Client Handbook: https://jeffersondrc.wufoo.com/forms/r1fntem81elc6ct/
Behavioral
Health Screen: https://www.surveymonkey.com/r/87FLFS9
Tobacco Screen: https://www.surveymonkey.com/r/LVVGQ7P
Release of Information (TH): https://jeffersondrc.wufoo.com/forms/rb2c0yf0fw18cc/
