Community Services Intake Form

Please complete the form below to seek our community-based services (counseling, advocacy, groups or classes.) If you need emergency shelter, please call our 24/7 line at 1.800.291.2139 (select "1" to speak with someone.). Please note that Safe Harbor services are voluntary and should be initiated by the person seeking services, not by a service provider, loved one or third party.

Once you complete the form below, we will be in touch within five to seven (5-7) business days. Please be sure to include a phone number and/or email address where you can be safely reached. Please be sure to check your voicemail and/or spam/junk mail folder (for email correspondences). If you have not heard from a member of our team within 5-7 business days of submitting this form, or if you have safety concerns, please contact us at info@safeharborsc.org or 1.800.291.2139. You can also visit our safety planning page. Thank you!

I have read and understand these intake agreements: Safe Harbor offers services to survivors of domestic violence in Greenville, Anderson, Pickens and Oconee Counties in South Carolina. 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

Date of Birth Please enter a valid date

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 select the service(s) you need: Counseling Case Management Support Groups Domestic Violence Education Classes Parenting Classes

Please select the service(s) you need: is required

Please briefly share why you are seeking Safe Harbor's services. Please briefly share why you are seeking Safe Harbor's services. is required

How long has the abuse been going on?

Have their abusive behaviors increased over the past 30 days? Yes No Unsure

If you have left or if you try to leave, would they try to find or follow you? Yes No Unsure

Are you afraid of them? Yes No Unsure

Do they have access to firearms? Yes No Unsure

Have they ever threatened to harm you or themselves? Yes No Unsure

Do they isolate you from your family or friends? Yes No Unsure

Have they ever withheld or threatened to withhold your basic needs for survival (ex. food, medication, money, etc.)? Yes No Unsure

Have they ever been arrested for domestic violence or assault? Yes No Unsure

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

Authorization Code

CALL US 24/7 - 1-800-291-2139

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Community Services Intake Form

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