Order of Protection Assistance Intake Form

Please complete the form below to seek assistance with completing an Order of Protection petition. If you need emergency shelter, please call our 24/7 line at 1.800.291.2139 (select "1" to speak with someone).

To learn more about Orders of Protection, please visit our Orders of Protection Assistance page.

Once you complete the form below, we will be in touch within 3 business days. Please be sure to include a phone number and/or email address where you can be safely reached. If you have not heard from us within 3 business days of submitting this form, please contact us at info@safeharborsc.org or at 1.800.291.2139. Thank you!

I have read and understand these intake agreements: Please fill out the entire form, including a safe phone number or email address. Please be sure that your voicemail is set-up and/or that your email is working so that we can successfully and safely reach you. This intake form is for individuals who are seeking Order of Protection assistance at Safe Harbor. If you need shelter, please call our 24/7 line at 1.800.291.2139 and select option "1" to speak with someone. While our services are confidential, we have confidentiality limitations due to mandatory reporting requirements. If you disclose information about abuse or neglect of a child or a vulnerable adult (an adult who is unable to care for themselves independently), we are required to make a report to the Department of Social Services and/or law enforcement. If you disclose that you have plans to harm yourself or someone else, we are required to make a report to emergency services or law enforcement. It is your choice what to share in this online intake form.

I have read and understand these intake agreements: is required

First Name First Name is required

Last Name Last Name is required

Address Address is required

City City is required

State State is required

Zip Code Zip Code is required

Safe Phone Number Please enter a 10 digit phone number

Safe Email Address Please enter a valid email address

Have you previously used Safe Harbor's services? Yes No

Have you previously used Safe Harbor's services? is required

If "yes", please list the type of service and year when you previously participated in services.

Has the person who has been harming you ever participated in Safe Harbor's services? Yes No Unsure

Has the person who has been harming you ever participated in Safe Harbor's services? is required

Please check one or more boxes that describe your relationship to the person who harmed you. Spouse Ex-Spouse Parent of your child(ren) Partner who lives with you Partner who previously lived with you

Please check one or more boxes that describe your relationship to the person who harmed you. is required

Please briefly describe the most recent incident when he/she physically harmed you or threatened to physically harm you. Please briefly describe the most recent incident when he/she physically harmed you or threatened to physically harm you. is required

Was there an arrest or police report made due to the incident of abuse? Yes, a police report was made but no arrest Yes, a police report and an arrest was made No reports or arrests were made

Was there an arrest or police report made due to the incident of abuse? is required

Is he/she currently in jail? Yes No Unsure

Is he/she currently in jail? is required

If he/she is currently in jail, what facility are they in?

Do you currently have a Family Court case pending for separation, divorce, child custody or other legal matters? Yes No

Do you currently have a Family Court case pending for separation, divorce, child custody or other legal matters? is required

Have you ever filed for an Order of Protection in the past? Yes No Unsure

Have you ever filed for an Order of Protection in the past? is required

Please share any additional information you would like for us to know.