Quickly Exit Site

Click on this button when your abuser enters the room. This page will be changed to Google.

Quickly Exit Site

[email protected]

Helpline: 1-347-394-5414

Facebook-f Instagram Linkedin Youtube Pillars Of Peace

Quickly Exit Site

About Us
Our Programs And Initiatives
Resources
Get Connected
- Events
- Careers
- Referrals
- Contact Us
- Donate

Menu

About Us
Our Programs And Initiatives
Resources
Get Connected
- Events
- Careers
- Referrals
- Contact Us
- Donate

Donate Now

About Us
Our Programs And Initiatives
Resources
Get Connected
- Events
- Careers
- Referrals
- Contact Us
Donate

Menu

About Us
Our Programs And Initiatives
Resources
Get Connected
- Events
- Careers
- Referrals
- Contact Us
Donate

Referral Form

Are You Requesting Services or Referring a Client?

I Am Requesting Services

I Am Referring A Client

1 – Name Of Individual Submitting Referral

2 – Name of Agency Submitting Referral

3 – How Did You Hear About Us

4 – Email Address of Individual Submitting the Referral

5 – Phone Number of Individual Submitting the Referral

6a – Client/Community Member’s First Name

6b – Client/Community Member’s Last Name

7 – Client/Community Member’s Date of Birth

8 – Client/Community Member’s Borough

9 – Client/Community Member’s Zip Code

10 – Client/Community Member’s Primary Language

11 – What Is the Client/Community Member’s Fluency in English?

Beginners/Limited

Intermediate

Advanced/Proficient

Native

12 – Safe Contact Information for the Client/Community Member

Phone

Email

12a – Phone

12b – Email

14 – Program to Which You Are Making a Referral

Hope & Healing (Counseling Services)

Resilience & Stability (Case Management Services)

Financial Relief Program

Housing-Related Inquiries

13 – What Is the Best Way to Reach the Client? (Please Include Any Information About the Best Method, Means, and Time of Contact That Will Help the Referred Program Successfully Connect With Your Client)

1a – Your First Name

1b – Your Last Name

2 – Your Date of Birth

3 – Your Email Address

4 – Your Phone Number

5 – What Borough Do You Live In?

6 – Your Zip Code

7 – Your Primary Language?

8 – Your Fluency in English?

Beginners/Limited

Intermediate

Advanced/Proficient

Native

9 – Your Safe Contact Information

Phone

Email

9a – Phone

9b – Email

10 – What Is the Best Way to Reach You? (Please Include Any Information About the Best Method, Means, and Time of Contact That Will Help Us Successfully Connect With You)

11 – Program to Which You Are Making a Referral

Hope & Healing (Counseling Services)

Resilience & Stability (Case Management Services)

Financial Relief Program

Housing-Related Inquiries

12 – How Did You Hear About Us

You Can Print a Copy of Your Answers After You Submit

If you are in immediate danger

call 9-1-1

For anonymous, confidential help 24/7, please call the National Domestic Violence Hotline at

1-800-799-7233 (SAFE) or 1-800-787-3224 (TTY)

Quick Links

Donate
Careers
Contact Us
Privacy Policy
Terms of Use

Donate
Careers
Contact Us
Privacy Policy
Terms of Use

Donate
Careers
Contact Us
Privacy Policy
Terms of Use

Donate
Careers
Contact Us
Privacy Policy
Terms of Use