First Name *

Last Name *

Email *

Phone *

Date of birth *

Consent for Communication

By checking this box, I consent to receive transactional messages from We Level Up related to my account, appointments, orders, or services I have requested. These may include appointment reminders, confirmations, and important account notifications. Message frequency may vary. Message and data rates may apply. Reply HELP for assistance or STOP to opt out.

I also consent to receive marketing and promotional messages from We Level Up, including special offers, event updates, wellness tips, and new program announcements.Message frequency may vary. Message and data rates may apply. Reply HELP for assistance or STOP to opt out.

Address *

Street Address

City

State

Country

Postal Code

Are you seeking help for drug, alcohol, or mental health issues? *

What kind of support have you received in the past, if any? *

Type of help substance use, mental health or alcoholism ? *

What inspired you to reach out today? *

Do you have Insurance *

How do you currently receive your insurance? *

Let's check what your insurance can cover. *

Can you upload a photo of your insurance card? *