General Referral Form

Please text or call (980) 721-7268 to let us know to expect this referral. Email b.cote@impactdv.org 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 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.