Safe Harbor Christian Counseling of Connecticut
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. 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. Download the Microsoft Word version of the form, fill it out, and attach it 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. ________________________________________________
Insurance Phone: _____________________________________________
Insurance Subscriber:  _________________________________________
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.