Telehealth Sites Intake Forms

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/

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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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