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
Address
Address 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.
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 his/her abusive behaviors increased over the past 30 days?
Yes
No
Unsure
If you have left or if you try to leave, would he/she try to find or follow you?
Yes
No
Unsure
Are you afraid of him/her?
Yes
No
Unsure
Does he/she have access to firearms?
Yes
No
Unsure
Has he/she ever threatened to harm you or him/herself?
Yes
No
Unsure
Does he/she isolate you from your family or friends?
Yes
No
Unsure
Has he/she ever withheld or threatened to withhold your basic needs for survival (ex. food, medication, money, etc.)?
Yes
No
Unsure
Has he/she ever been arrested for domestic violence or assault?
Yes
No
Unsure
Please share any additional information you would like for us to know.