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Intake Form

Home > Services > Psychiatric Assessment & Evaluation and Medication Management > Intake Form

Please provide the following information in the form:

  • Intake Info
  • Addendum to Intake Forms
  • Notice of Privacy Practices

Contact Details We Would Love to Hear from You

You are always free to reach out to us anytime. Feel free to use the provided contact information below for your convenience.

  • Mental Health Services

    106 Doctors Park, Lincolnton, NC 28092

    Phone: 704-732-2006
    Fax: 704-732-0303
  • DWI Services and Mental Health Services

    1409 East Boulevard, Suite 100, Charlotte, NC 28303

    Phone: 704-338-1155
    Fax: 704-342-1917
  • You can message us through our email Email Address: impactcarolina@aol.com
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