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Dec 23 2025

December 23, 2025 @ 8:00 am - 5:00 pm

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Thank you for your interest in booking with Safe Harbor!

Are you in crisis? If so, please call 911 immediately.

To confirm your booking, we’ll need to collect some information regarding your personal information, insurance policy, and billing information.
This process may take several minutes to complete.

Before you begin, please have the following information nearby:

Personal information of the patient and any responsible parties or guardians.
Insurance Cards
Payment Information for future copays.

Continue

1Personal Information

2Responsible Party Information

3Legal Guardian Information

4Insurance Information

5Payment Information

6Visit Reason

Personal Information

Patient Contact Information

Please complete the following section with your legal information as it appears on your insurance card (if applicable):

First Name

Last Name

Date of Birth

MM slash DD slash YYYY

Phone Number

Address

Street Address City State / Province / Region ZIP / Postal Code

Patient Personal Information

Gender Assigned at Birth (sex)

Male

Female

Gender Identity

Pronouns

Sexual Orientation

Marital Status

Responsible Party Information

Are you completing this form for someone else?

Yes

What is your relationship to the patient?

Are you the responsible party for billing?*

Yes

First Name

Last Name

Phone Number

Address

Street Address City State / Province / Region ZIP / Postal Code

Gender Assigned at Birth (sex)

Male

Female

Legal Guardian Information

Are you completing this form for a minor?

Yes

First Name

Last Name

Legal Guardian Relationship to Patient

Phone Number

Address

Street Address City State / Province / Region ZIP / Postal Code

Do you have a custody agreement on file?

Yes

Insurance Information

Insurance Carrier

Member ID

Group Number

Effective Date of Coverage (EDOC)

MM slash DD slash YYYY

Coverage Type

Name of Policy Holder (if other than patient)

Relationship to Patient

Insurance Carrier Phone

Do you have a secondary insurance?

Yes

Secondary Insurance Carrier

Member ID

Group Number

Effective Date of Coverage (EDOC)

MM slash DD slash YYYY

Coverage Type

Name of Policy Holder (if other than patient)

Relationship to Patient

Insurance Carrier Phone

Payment Information

A credit card is required to be placed on file, and please note it is fully encrypted within our system. No one can view or access your card information. Our benefits department will verify your insurance coverage to confirm that services are in-network. Your card will only be charged if a copay or coinsurance applies, typically 1–3 business days after your appointment. For this initial appointment, there is no late cancellation or missed appointment fee; however, we ask that you call our oﬃce if you need to cancel. Additional information can be found under our financial policies in your intake paperwork.

Card Type

Card Number

CVV

Expiration Date

MM slash DD slash YYYY

Cardholder Name (as it appears on the card)

Billing Street

Billing Zip Code

Visit Reason

May we let your provider know the reason for your visit?

Select your visit reason below

How did you hear about us?

A Friend or Family Member

My Doctor

Online Search

Radio Ad

Social Media

Other