General 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.

 
(Referrer) Name *
(Referrer) Name
(Referrer) Phone *
(Referrer) Phone
(Referrer) Supervisor Name *
(Referrer) Supervisor Name
Client Name *
Client Name
Client DOB *
Client DOB
Client Phone Number *
Client Phone Number
Date client reports to Impact: *
Date client reports to Impact:
DV-related criminal charges, behavior and restraining orders
Non-DV-related charges Substance abuse Mental Illness Other