Create an Appointment at East Bay Sanctuary Covenant
Please answer the questions below to create an appointment at East Bay Sanctuary Covenant. The questions on this form will help us to better connect you with our services, and your information is completely confidential. We will not share your answers with anyone who does not work at the East Bay Sanctuary Covenant. However, if you prefer not to answer a question, you may skip it.

Please note that filling out this form does not guarantee that you will be given an appointment at EBSC, nor does it guarantee that we will be able to help you.
Are you a new client? *
What is your name?
You may skip this question if you prefer not to answer.
Your answer
What is your phone number? *
Your answer
Can we text you? *
What is your email address, if you have one?
You may skip this question if you prefer not to answer.
Your answer
What language(s) do you speak fluently?
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