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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:  
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.

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