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: 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 community-based services at Safe Harbor only. 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 some 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 Line 1 Address Line 1 is required

City City is required

State State is required

Zip Code Zip Code is required

Safe Email Address Please enter a valid email address

Safe Phone Number Please enter a 10 digit phone number

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.