Due to increasing use of this request form for treatment concerns, the form has been disabled and we can no longer accept email through the website.

If you would like to be added to our email list to receive information about events at The Center, please call 614.896.8251.

For all other questions or for treatment, call 614.896.8222.


 

 

8001 Ravines Edge Ct
Columbus, OH, 43235

6148968222

New Client Request Form

Request for Help

Name *
Name
I am seeking help for *
Phone *
Phone
I can best be reached during these times *
Calls are made Monday-Friday, except holidays
It is okay to leave a message for me at this number *
The following questions will help us learn a bit about you and allow us to properly route your request.
Do you make yourself sick because you feel uncomfortably full? *
Do you worry you have lost control over how much you eat? *
Have you recently lost more than 14 lbs (6.35 kg) in a three - month period? *
Do you believe yourself to be fat when others say you are too thin? *
Would you say food dominates your life? *
Are you satisfied with your eating patterns? *
Do you ever eat in secret? *
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.