Request Services

Request services or make a referral

Use this form to request services or make a referral. We will contact you within one business day. Each parent will complete a separate, private intake after we accept the case.

Safety notice

Do not use this form in an emergency. If you are in danger, call 911. If you are worried someone may see your device, use a safe device or call us instead at 251-524-3965.

About you

I am a *

Your full name *

Organization or law firm

Your phone *

Your email *

Best time and safest way to contact you

Case information

Court and county

Court

Case number

Service requested *

Number of children and their ages

Ages only, please. Do not include names.

Upload the court order (optional)PDF or image, up to 10 MB

Brief note (optional)

Please do not include addresses or detailed allegations. We will discuss details privately at intake.

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I understand this form is not for emergencies and that submitting it does not schedule a visit.

We use the information you provide only to respond to your request. We do not collect the other parent's contact information on this form.

Prefer to talk? Call 251-524-3965 or email info@safeharbourvisit.org.