I AM LOOKING FOR HELP FOR *


 
WHAT ARE YOU STRUGGLING WITH *

PLEASE CHOSE WHAT YOU ARE HAVING A PROBLEM WITH

 
ARE YOU WILLING TO GO TO TREATMENT *

Do You Want To Stop Using {{answer_23253499}}

 
WHAT DESCRIBES YOUR CURRENT SITUATION *

You Could Be Getting Into Treatment Today For  {{answer_23253499}} Dont wait another day to get your life back!

 
FIRST NAME OF PERSON THAT NEEDS HELP *

Lets get you the help you need for your {{answer_23253499}} problem. Your {{answer_23254055}} Health Insurance may cover 100% of the costs of treatment.
 
LAST NAME OF PERSON THAT NEEDS HELP *

{{answer_23254142}}, we need your last name to verify what your {{answer_23254055}} Health Insurance will cover for your treatment.
 
{{answer_23254142}} we are checking to see what your {{answer_23254055}} Health Insurance covers for your {{answer_23253499}} Treatment. This will only take a few seconds! 

You Don’t Have To Feel This Way Anymore

 
VERIFICATION STEP *

{{answer_23254142}} Your {{answer_23254055}} Health Insurance needs to verify your coverage for {{answer_23253499}}. To receive your verification by text please enter your Phone Number below.
 
{{answer_23254142}} Please click I Accept to Verify Your Benefits. *

By clicking the button “I Accept” you verify your information is correct and consent to receive your insurance verification of benefits information to the email you have provided. You may also receive a text message at the telephone number you provided above confirming your request.You may also receive your Insurance verification of benefits by contacting us via phone. You may receive phone calls from our automated dialer system. You may revoke this consent at any time by contacting us via phone to be placed on our do-not-call list. Your carrier's message and data rates may apply. CleanAndSoberLife.org does not charge you for sending or receiving text messages. By using this form you agree to the terms of our privacy policy.
     
{{answer_23254142}} Your New Life Starts Today.  You have Treatment Options available to you in {{answer_23253912}} You will receive a text in a few minutes if your treatment options are verified. If your treatment options are approved you will receive a phone call. For immediate help call 888-743-8618.
Continue