5-Day Program Request Form

Call us at 614.896.8222
Fill out the form below and we will contact you within 2 business days.

Name *
I am seeking help for *
The person I am seeking help for is age 16 or older *
Phone *
It is okay to leave a message for me at this number *
It is okay to contact me via email. *
The following questions will help us learn a bit about you and allow us to properly route your request.
I understand and agree to the terms *
By clicking “submit” below, you are indicating that you understand and agree to these terms: You understand that this form submission is NOT to be used for emergency care. We are not a crisis facility. In an emergency situation, you need to call 911 or go to your nearest emergency room. You understand that we will contact you Monday-Friday, except holidays, during our regular business hours. The information you submit on this form will be used internally to contact you. You grant us permission to call you at the number provided. A message will only be left if you have indicated we can do so.