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

Monday               8 AM-6 PM

Tuesday               8 AM-7 PM

Wednesday        8 AM-8 PM

Thursday             8 AM-5 PM

Friday                   8 AM-5 PM

Saturday              9 AM-3 PM

Sunday                 CLOSED

For an appointment call 304-728-3527

***Holiday Schedule will follow State and Federal Holiday Schedule.***

For closings or delays, please see our Facebook page - Jefferson Day Report Center

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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: