gethelp.salvationarmyusa.org Open in urlscan Pro
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1 forms found in the DOM

POST /?c_src2=20220412_378376_104416196&eid=email%3A20220412_ARC_Impact_Newsletter%3A%3Asfmc%3A%3A%3A20220412_378376_104416196%3A%3AUSW%3AGetHelpNow%3A#gf_2

<form method="post" enctype="multipart/form-data" target="gform_ajax_frame_2" id="gform_2"
  action="/?c_src2=20220412_378376_104416196&amp;eid=email%3A20220412_ARC_Impact_Newsletter%3A%3Asfmc%3A%3A%3A20220412_378376_104416196%3A%3AUSW%3AGetHelpNow%3A#gf_2" novalidate="">
  <div class="gform_body gform-body">
    <ul id="gform_fields_2" class="gform_fields top_label form_sublabel_below description_below">
      <li id="field_2_1" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">Who Needs Help?<span class="gfield_required"><span
              class="gfield_required gfield_required_asterisk">*</span></span></label>
        <div class="ginput_container ginput_container_radio">
          <ul class="gfield_radio" id="input_2_1">
            <li class="gchoice gchoice_2_1_0">
              <input name="input_1" type="radio" value="Me" checked="checked" id="choice_2_1_0">
              <label for="choice_2_1_0" id="label_2_1_0">Me</label>
            </li>
            <li class="gchoice gchoice_2_1_1">
              <input name="input_1" type="radio" value="A Loved One" id="choice_2_1_1">
              <label for="choice_2_1_1" id="label_2_1_1">A Loved One</label>
            </li>
          </ul>
        </div>
      </li>
      <li id="field_2_5" class="gfield gfield--width-full me gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_2_5">Your ZIP Code<span class="gfield_required"><span
              class="gfield_required gfield_required_asterisk">*</span></span></label>
        <div class="ginput_container ginput_container_text"><input name="input_5" id="input_2_5" type="text" value="" class="medium" aria-required="true" aria-invalid="false"> </div>
      </li>
      <li id="field_2_13" class="gfield gfield--width-full loved-one gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" style="display: none;"><label class="gfield_label" for="input_2_13"
          style="display: none;">Loved One's ZIP Code<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
        <div class="ginput_container ginput_container_text"><input name="input_13" id="input_2_13" type="text" value="" class="large" aria-required="true" aria-invalid="false" disabled="" style="display: none;"> </div>
      </li>
      <li id="field_2_14" class="gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" style="display: none;"><label class="gfield_label">Interested In<span
            class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
        <div class="ginput_container ginput_container_radio">
          <ul class="gfield_radio" id="input_2_14">
            <li class="gchoice gchoice_2_14_0">
              <input name="input_14" type="radio" value="Men's Program" checked="checked" id="choice_2_14_0">
              <label for="choice_2_14_0" id="label_2_14_0">Men's Program</label>
            </li>
            <li class="gchoice gchoice_2_14_1">
              <input name="input_14" type="radio" value="Women's Program" id="choice_2_14_1">
              <label for="choice_2_14_1" id="label_2_14_1">Women's Program</label>
            </li>
          </ul>
        </div>
      </li>
      <li id="field_2_8" class="gfield loved-one gfield_contains_required field_sublabel_hidden_label field_description_below gfield_visibility_visible" style="display: none;"><label class="gfield_label gfield_label_before_complex"
          style="display: none;">Loved One's First Name<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
        <div class="ginput_complex ginput_container no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name" id="input_2_8">
          <span id="input_2_8_3_container" class="name_first">
            <input type="text" name="input_8.3" id="input_2_8_3" value="" aria-required="true" disabled="" style="display: none;">
            <label for="input_2_8_3" class="hidden_sub_label screen-reader-text">First</label>
          </span>
        </div>
      </li>
      <li id="field_2_9" class="gfield loved-one gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" style="display: none;"><label class="gfield_label" for="input_2_9" style="display: none;">Loved One's
          Age<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
        <div class="ginput_container ginput_container_number"><input name="input_9" id="input_2_9" type="number" step="any" min="0" max="120" value="" class="medium" aria-required="true" aria-invalid="false" aria-describedby="gfield_instruction_2_9"
            disabled="" style="display: none;">
          <div class="instruction " id="gfield_instruction_2_9">Please enter a number from <strong>0</strong> to <strong>120</strong>.</div>
        </div>
      </li>
      <li id="field_2_12" class="gfield gfield_contains_required field_sublabel_hidden_label field_description_below gfield_visibility_visible"><label class="gfield_label gfield_label_before_complex">Your First Name<span class="gfield_required"><span
              class="gfield_required gfield_required_asterisk">*</span></span></label>
        <div class="ginput_complex ginput_container no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name" id="input_2_12">
          <span id="input_2_12_3_container" class="name_first">
            <input type="text" name="input_12.3" id="input_2_12_3" value="" aria-required="true">
            <label for="input_2_12_3" class="hidden_sub_label screen-reader-text">First</label>
          </span>
        </div>
      </li>
      <li id="field_2_2" class="gfield me gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_2_2">Your Age<span class="gfield_required"><span
              class="gfield_required gfield_required_asterisk">*</span></span></label>
        <div class="ginput_container ginput_container_number"><input name="input_2" id="input_2_2" type="text" step="any" min="0" max="120" value="" class="medium" aria-required="true" aria-invalid="false" aria-describedby="gfield_instruction_2_2">
          <div class="instruction " id="gfield_instruction_2_2">Please enter a number less than or equal to <strong>120</strong>.</div>
        </div>
      </li>
      <li id="field_2_3" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_2_3">Your Phone<span class="gfield_required"><span
              class="gfield_required gfield_required_asterisk">*</span></span></label>
        <div class="ginput_container ginput_container_phone"><input name="input_3" id="input_2_3" type="tel" value="" class="medium" aria-required="true" aria-invalid="false"></div>
      </li>
      <li id="field_2_4" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_2_4">Your Email<span class="gfield_required"><span
              class="gfield_required gfield_required_asterisk">*</span></span></label>
        <div class="ginput_container ginput_container_email">
          <input name="input_4" id="input_2_4" type="email" value="" class="medium" aria-required="true" aria-invalid="false">
        </div>
      </li>
      <li id="field_2_7" class="gfield field_admin_only field_sublabel_below field_description_below gfield_visibility_administrative"><input name="input_7" id="input_2_7" class="gform_hidden" type="hidden" value=""></li>
      <li id="field_2_6" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_2_6">Specific Instructions</label>
        <div class="ginput_container ginput_container_textarea"><textarea name="input_6" id="input_2_6" class="textarea medium" placeholder="e.g., best method of contact, best time to call, reason for inquiry, etc." aria-invalid="false" rows="10"
            cols="50"></textarea></div>
      </li>
      <li id="field_2_15" class="gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_hidden">
        <script type="text/javascript">
          jQuery(document).on('gform_post_render', function(event, form_id, current_page) {
            if (jQuery('#field_2_7 input').val() != 'USW') {
              jQuery('#field_2_14').hide().prop('disabled', true);
              console.log('Me');
            }
            jQuery('#choice_2_1_0').click(function() {
              jQuery('.me, .me input, .me label').show().prop('disabled', false);
              jQuery('.loved-one, .loved-one input, .loved-one label.gfield_label').hide().prop('disabled', true);
              jQuery('.me').removeClass('gfield_visibility_hidden');
              jQuery('.admin-hidden-markup').remove();
              console.log('Me');
            });
            jQuery('#choice_2_1_1').click(function(e) {
              jQuery('.loved-one, .loved-one input, .loved-one label.gfield_label').show().prop('disabled', false).removeAttr('disabled');
              jQuery('.me, .me input, .me label').hide().prop('disabled', true);
              jQuery('.loved-one').removeClass('gfield_visibility_hidden');
              jQuery('.admin-hidden-markup').remove();
              console.log('Loved One');
            });
          });
        </script>
      </li>
    </ul>
  </div>
  <div class="gform_footer top_label"> <input type="submit" id="gform_submit_button_2" class="gform_button button" value="Submit"
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      onkeypress="if( event.keyCode == 13 ){ if(window[&quot;gf_submitting_2&quot;]){return false;} if( !jQuery(&quot;#gform_2&quot;)[0].checkValidity || jQuery(&quot;#gform_2&quot;)[0].checkValidity()){window[&quot;gf_submitting_2&quot;]=true;}  jQuery(&quot;#gform_2&quot;).trigger(&quot;submit&quot;,[true]); }">
    <input type="hidden" name="gform_ajax" value="form_id=2&amp;title=1&amp;description=1&amp;tabindex=0">
    <input type="hidden" class="gform_hidden" name="is_submit_2" value="1">
    <input type="hidden" class="gform_hidden" name="gform_submit" value="2">
    <input type="hidden" class="gform_hidden" name="gform_unique_id" value="">
    <input type="hidden" class="gform_hidden" name="state_2" value="WyJ7XCIxNFwiOltcIjZlOTAxNzJjYzdiMWIxYWJlYzIyOWRhMmQyYjY0MTAzXCIsXCJjMGQ4Mzc0ZDA4NzRiMmE3NDg2ZWVmNmYyZDhjYWE3YVwiXX0iLCI2OGVlNWNiOWI1MTE5ZDY3NTc5MmIyOGRkODc5NDExOSJd">
    <input type="hidden" class="gform_hidden" name="gform_target_page_number_2" id="gform_target_page_number_2" value="0">
    <input type="hidden" class="gform_hidden" name="gform_source_page_number_2" id="gform_source_page_number_2" value="1">
    <input type="hidden" name="gform_field_values" value="">
  </div>
</form>

Text Content

 * Salvation Army – Doing the most good
 * Get Help Today
 * Contact Us 1-800-728-7825

The Salvation Army Adult Rehabilitation Center is a faith-based work therapy
program for those struggling with alcohol and substance abuse. It is provided at
NO COST to you.

Watch a personal testimony of a life changed.

View more info on our rehabilitation centers.

Contact us by phone at 1-800-728-7825


GET HELP NOW

*Required
 * Who Needs Help?*
    * Me
    * A Loved One

 * Your ZIP Code*
   
 * Loved One's ZIP Code*
   
 * Interested In*
    * Men's Program
    * Women's Program

 * Loved One's First Name*
   First
 * Loved One's Age*
   Please enter a number from 0 to 120.
 * Your First Name*
   First
 * Your Age*
   Please enter a number less than or equal to 120.
 * Your Phone*
   
 * Your Email*
   
 * 
 * Specific Instructions
   
 * 


 * Privacy Policy

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