Make a referral for a DHHR evaluation - Charleston, WV

DHHR Referral Form (all evaluations except for juvenile disposition require court orders guaranteeing payment)

* Indicates required field

Type of Evaluation *

Name of Person Sending Referral *

First

Last

Agency *

Phone Number *

County *

Email *

Judge *

First

Last

Prosecutor *

First

Last

GAL *

First

Last

Attorney for Person to be Evaluated *

First

Last

Name of Person to be Evaluated (if reunification, one of the parents goes here) *

First

Last

FACTS Client ID # *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Date of Birth *

Social Security Number *

Brief Explanation of Reason for Evaluation *

Date Completed Report Needed (specify time if prior to close of business) *

For reunification evaluations only, please complete the sections below:

Name of Other Parent *

First

Last

Other Parent's Attorney *

First

Last

Date of Birth *

Social Security Number *

Children's Names (ages) *

Other Parties (relationship to family) *

Submit