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 seven (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 three 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:
I have read and understand these intake agreements: is required
First Name is required
Last Name is required
Please enter a valid date
Address is required
City is required
State is required
Zip Code is required
Please enter a 10 digit phone number
Please enter a valid email address
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 their abusive behaviors increased over the past 30 days?
If you have left or if you try to leave, would they try to find or follow you?
Are you afraid of them?
Do they have access to firearms?
Have they ever threatened to harm you or themselves?
Do they isolate you from your family or friends?
Have they ever withheld or threatened to withhold your basic needs for survival (ex. food, medication, money, etc.)?
Have they ever been arrested for domestic violence or assault?

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