Secure Individual Enrollment Form

First Name *

Last Name *

Gender: *

---MaleFemaleOther

Date of Birth: *

If you are on an iPhone and using iOS 14, you may need to double tap on the line below.

Home City *

Home State *

Email *

Mobile Phone Number: *

Emergency Contact First Name *

Emergency Contact Last Name *

Emergency Contact Phone Number: *

Referral Source *

I am an individual in recovery for a substance use disorder: *

---YesNo

I am a WV College Student: *

---YesNo

If yes to student, which College? (for informational purposes only. We do not share this information):
---BlueRidge Community and Technical CollegeBridgevalley Community and Technical College, MontgomeryBridgevalley Community and Technical College, South CharlestonEastern WV Community and Technical collegeMountwest Community and Technical CollegeNew River Community and Technical CollegePierpont Community and Technical CollegeSouthern WV Community and Technical CollegeWest Virginia Northern Community CollegeWest Virginia University at ParkersburgBluefield State CollegeConcord UniversityFairmont State UniversityGlenville State CollegeMarshall UniversityShepherd UniversityWest Liberty UniversityWest Virginia School of Osteopathic MedicineWest Virginia State UniversityWVU Potomac State CollegeWest Virginia UniversityWest Virginia University Institute of technologyAlderson Broaddus UniversityAppalachian Bible CollegeBethany CollegeDavis and Elkins CollegeOhio Valley UniversityUniversity of CharlestonWest Virginia Wesleyan CollegeWheeling UniversityOther

Current Treatment Provider(s), or "none" if not in treatment: *

Health Plan / Insurance (for informational purposes only. Your insurance will not be charged):
---WV Medicaid-UnicareWV Medicard-The Health PlanWV Medicaid-Aetna Better HealthWV MedicaidMedicareHighmark BCBSCareSourceOtherUninsuredUnknown

Comment:

Be sure to double check your mobile phone number in the form. You will be receiving a text message from (610) 488-2461 with a link to download the Connections App

Δ