Request an Appointment
For faster response, please call our intake department directly at 800-305-2089 and choose Option 1 during the business hours of 9am-5pm Monday-Friday.
Name:
*
First Name
Last Name
Best phone number to reach you:
*
Please enter a valid phone number.
Is it okay to leave you a message or text you at this number?
Yes to voice messages & text
Text me only
No voice message or text, call only
Other
Alternate Phone (optional):
Please enter a valid phone number.
Email:
*
example@example.com
City and/or County of Residence:
*
Providing this information helps us to narrow down appointment availability.
State of Residence:
*
Type of Counseling you are looking for (please check all that apply):
*
Individual counseling for myself
Individual counseling for my child (under age of 16)
Marriage counseling
Family counseling
Medication Management with a Nurse Practitioner
Other
Please briefly describe the type of services you are looking for (help with anxiety, someone with trauma experience, a female counselor, etc.):
Type of Insurance
In order to verify your insurance benefits for you and potentially secure an appointment for you faster, please provide us with the type of Insurance you have. You can skip this section and upload a copy of your insurance card below if that is easier.
Name of Insurance Carrier & Plan (i.e. CareFirst, Johns Hopkins, etc.). If you do not carry insurance, please type 'none':
*
Policy #:
Group #:
If you would like, you can upload a copy of your insurance card instead of typing in the information (not required):
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How did you hear about us?
*
Google
Friend/Family
PCP/Medical Professional Referred Me
My insurance company
Psychology Today website
I'm a former patient of Safe Harbor
Radio ad
Pastor or church referred me (enter name below)
Other
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