Full Name

Phone *

Email *

Who Needs Support? *

Date of birth of the person who needs support? *

Child's First Name (skip if this is for yourself)

Child's Age (skip if this is for yourself)

How many children are you seeking support for? (skip if this is for yourself)

Tell us about your other children

Are you from Innovators of the Future?

Service Needed *

Preferred Location

Insurance Type *

Are you okay with virtual (video) support sessions? *

Safe Harbor offers outpatient counseling with licensed counselors. We do not offer psychiatry (medication) or psychological evaluations (testing). Does that fit what you need? *

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