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Safe Harbor Christian Counseling
New Client Appointment Form

To make an appointment, please fill out the form below and click submit. A client service representative will review your information and get back to you with availability.

Or, you can print out a form, and fax it to 410-569-0094.

You may call us toll-free at 800-305-2089 to speak to a client service representative.

Please Note: Fields in bold with an '*' are required. All others are optional.

Today's Date:  
*First Name:  
*Last Name:  
Address:  
City:  
STATE:    in United States
Zip/Postal Code:  
Phone Number:  
*Email Address:  
Insurance Company:  
Insurance Company Phone:  
Insurance Subscriber Name:  
Subscriber Date of Birth:  
Subscriber Policy #:  
Group #:  
Subscriber SSN:  
Subscriber Employer:  
Client's Relationship to Subscriber:  
Client's Date of Birth:  
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?:  

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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 provide you with an ideal appointment time.



Safe Harbor Christian Counseling Participates in Research Study - Find Out More
1st Annual Health and Wellness Conference, Oct 4, 2014, Bowie, MD