*To expedite admission to Turning Pointe, please have your attorney, CPS worker, or probation/parole officer contact us at 304-252-6783 or fax to 304-252-6796.

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Date *
Date
Person Completing Referral: *
Person Completing Referral:
Name *
Name
Phone *
Phone
Referrals must include a valid phone number for contact.
Date of Birth *
Date of Birth
Address
Address
Medicaid
Pregnant or Post-Partum?
Due Date
Due Date
If pregnant, you must provide a proof of pregnancy in order for this application to be processed.
Post-Partum: Baby's DOB:
Post-Partum: Baby's DOB:
Emergency Contact
Emergency Contact
Emergency Contact Phone
Emergency Contact Phone
Date of Last Drug Use 1:
Date of Last Drug Use 1:
Date of Last Drug Use 2:
Date of Last Drug Use 2:
Date of Last Drug Use 3:
Date of Last Drug Use 3:
Program Name and dates attended.
Currently:
Please explain.
Please list all relevant contact information: