Make An Appointment
Safe Harbor Christian Counseling of Connecticut
NEW CLIENTS - APPOINTMENT FORM
Instructions: 4 easy ways to make an appointment.
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.
NEW CLIENTS - APPOINTMENT FORM
Instructions: 4 easy ways to make an appointment.
- Print this form, and fax to our confidential fax at 410-569-0094.
- 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.
- Download the Microsoft Word version of the form, fill it out, and attach it in an e-mail to ruth@safeharbor1.com.
- 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.