Contact Us

Harris Community Care has 2 offices to serve you.
Martisnburg, WV Office
Berkeley, Morgan & Jefferson
709 W. Burke Street, Martinsburg, WV 25401
Local: 304-263-7764 | Toll Free: 877-513-7976
Email: [email protected]
Romney, WV Office
Hampshire, Hardy & Mineral
500 E. Main Street, Romney, WV 26757
Local: 304-822-8210 | Toll Free: 877-385-8815
Email: [email protected]


Client Intake Form
Downloadable Forms: Acrobat PDF or Microsoft Word

Or fill out this online form....
The required fields appears with a red * at the end of the field.

Your Name:   

 *

Email:   

 *
   Perspective Client Information

Perspective Client Name:   

 *

Street Address:   

 *

City:   

 *

State:   

 *

Zip:   

 *

Date Of Birth:   

 *

Age:   

 *

   Resides (select if):   

If living with someone, whom:   

   Marital Status:   

 *
   Emergency Contact Information

Contact:   

 *

Phone:   

 *

Street Address:   

 *

City:   

 *

State:   

 *

Zip:   

 *

Doctor's Names:   

 *

Doctor's Address:   

 *

Illnesses/Conditions:   

 *
   Other Information

How soon do you need assistance?:   

 *

What hours/days do you need assistance?:   

 *

How or who referred you?:   

 *

Additional information you would like for us to know:   

 *

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Berkeley, Morgan & Jefferson
709 W. Burke Street
Martinsburg, WV 25401
Local: 304-263-7764
Toll Free: 877-513-7976
Email: Martinsburg Office
Hampshire, Hardy & Mineral
500 E. Main Street
Romney, WV 26757
Local: 304-822-8210
Toll Free: 877-385-8815
Email: Romney Office

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