(STEP 1 OF 2) COMPLETE THE APPLICATION BELOW BEFORE BOOKING YOUR CALL

We have two options to be able to help you. To better serve you, which best describes you?

Is alcohol negatively affecting your life?

Are you ready to solve this problem?

What area of your life is being affected the most by your drinking?

What kind of a drinker are you?

How often do you drink?

What is your biggest concern you have with your drinking?

What have you done previously to work on your relationship with alcohol?

Tell us about your previous attempts to deal with your relationship with alcohol - what works, what didn't work?

What do you want to do about your relationship with alcohol?

If someone advised you on how to get that would you...

What's your First Name?

What's your Last Name?

What is the best email to contact you at?

What is the best number to contact you at?

Right now, I _________

By answering this question you are granting us permission to communicate with you via email, SMS and phone calls.

IAMACOMEBACK LLC