DSS Referral Form

Please call (980) 721-7268 to let us know to expect this referral. Email b.cote@impactdv.org (or Fax (704) 535-5505) a copy of the judgment or restraining order, if applicable.

Thank you for your referral!

Please remember: it is the defendant’s responsibility to make an appointment for an intake and follow through with that and all appointments.  We will notify you by fax or email of his acceptance into the program.  We look forward to working with you. 

NOTE: Space is limited in some fields. Please email longer referrals (additional information) directly to b.cote@impactdv.org.

 
SW Name *
SW Name
Date *
Date
Phone *
Phone
Date of Birth *
Date of Birth
Agency has custody: *
Date to report to IMPACT: *
Date to report to IMPACT:
All Children:
Child Name
Child Name
DOB
DOB
Child Name
Child Name
DOB
DOB
Child Name
Child Name
DOB
DOB
Child Name
Child Name
DOB
DOB
History
THANK YOU