Counseling Services

Quigley House offers counseling services to survivors of domestic violence and sexual assault in Clay County. All services are free and confidential.

Quigley House Counseling Referral Form

Referral Source Information - Name

First Name

Last Name

Agency

Phone

(###)

###

####

Email

Date Sent

MM

DD

YYYY

Date Received

MM

DD

YYYY

Survivor Information - Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

Address

Number of Children

Safe Phone Number

(###)

###

####

Safe Time to Call

Safe to Leave a Voicemail

Abuser Information - Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

Relationship to Survivor

Resides with Survivor

Reason for referral/description

Authorization to Contact - Survivor Name

By signing below, I am requesting an advocate from Quigley House, Inc. contact me to offer support, resources, information, services, and safety planning for myself and my children. I understand that I may access services through Quigley House, Inc. whether I sign this referral form or not, by dialing the 24-hour Crisis Helpline at 904-284-0061.

First Name

Last Name

Date

MM

DD

YYYY