New Clients Appointment Form
Instructions: 4 easy ways to make an appointment.
1) Print this form and fax to our confidential fax at 410-569-0094.
2) Click the link to e-mail our client service representative - ruth@safeharbor1.com.
In the e-mail please provide the information on this form or just a phone number to call.
3) Click on this link for a Microsoft Word version of this form so that you can attach in an e-mail to ruth@safeharbor1.com.
4) Call toll free 800-305-2089 and speak to a client service representative.
Today's date: ______________________________
Name:__________________________________________________
Phone: _____________________________
Address: _______________________________________________________
Insurance Co. _____________________________________________
Phone: _____________________________
Insurance Subscriber: _________________________________
Date of birth:________________________
Subscriber Policy #: ________________________________________________
Group #:_________________________________________________________
Subscriber SS#: ___________________________________________________
Subscriber employer:________________________________________________
Client's relationship to subscriber: ______________________________________
Client's date of birth (if not subscriber): __________________________________
Desired appointment day (if any): ______________________________________
Desired appointment time:____________________________________________
Desired counselor name (if any): _______________________________________
Desired location(s): _________________________________________________
Brief explanation for seeking counseling: ________________________________________________________________
________________________________________________________________
________________________________________________________________
How did you hear about Safe Harbor?____________________________________
Please note that desired location, date of appointment and a particular counselor may not match what is available, but this information may help our client service rep to provide you with an ideal appointment time.