Community Services Intake Form

Please complete the form below to seek our community-based services. If you need emergency shelter, please call our 24/7 line at 1.800.291.2139. 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 a member of our team 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:
I have read and understand these intake agreements: is required
First Name is required
Last Name is required
Address Line 1 is required
City is required
State is required
Zip Code is required
Please enter a valid email address
Please enter a 10 digit phone number
Have you previously used Safe Harbor's services?
Have you previously used Safe Harbor's services? is required
Has the person who has been harming you ever participated in Safe Harbor's services?
Has the person who has been harming you ever participated in Safe Harbor's services? is required
Please select the service(s) you need:
Please select the service(s) you need: is required
Please briefly share why you are seeking Safe Harbor's services. is required
Have his/her abusive behaviors increased over the past 30 days?
If you have left or if you try to leave, would he/she try to find or follow you?
Are you afraid of him/her?
Does he/she have access to firearms?
Has he/she ever threatened to harm you or him/herself?
Does he/she isolate you from your family or friends?
Has he/she ever withheld or threatened to withhold your basic needs for survival (ex. food, medication, money, etc.)?
Has he/she ever been arrested for domestic violence or assault?

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