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Referral Form

All client Progress Reports are sent via our secure EHR Portal. 

If you have not set up an 'Authorized User' account yet, an invitation to activate this account will be sent to you shortly after you submit this form. (Check your SPAM folder if you don't receive it)

If you have any trouble getting your account set up,  please contact us at (304) 317-7776.

Referral Form

Person making referral details:

County
How often would you like a progress report?
Program/Service you are referring to
Payor Source
Is this a DHHR/CPS referral?

Please select YES if your referral is a DHHR or CPS-involved client.

County of record

Details on client or clients being referred:

Would you like to refer another client at this time?
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