function ap_validate_2758() {
   var form = document.ap_form_2758;
   var regexp_28325 = /^[a-zA-Z]+(([\'\,\.\-][a-zA-Z])?[a-zA-Z]*)*$/;
   var regexp_28230 = /^((\+\d{1,3}(-| )?\(?\d\)?(-| )?\d{1,3})|(\(?\d{2,3}\)?))(-| )?(\d{3,4})(-| )?(\d{4})(( x| ext)\d{1,5}){0,1}$/;
   var regexp_28227 = /^(([A-Za-z0-9]+_+)|([A-Za-z0-9]+\-+)|([A-Za-z0-9]+\.+)|([A-Za-z0-9]+\++))*[A-Za-z0-9]+@((\w+\-+)|(\w+\.))*\w{1,63}\.[a-zA-Z]{2,6}$/;
    if (form.name === ""){
      alert( "There was an error on this form." );
    } else if (form.ap_field_28325.value === ""){
      alert( "Please enter all required fields: Contact Name " );
    } else if (!regexp_28325.test(form.ap_field_28325.value)){
      form.ap_field_28325.focus();
      form.ap_field_28325.select();
      alert( "Please correct required field: Contact Name" );
    } else if (form.ap_field_28230.value === ""){
      alert( "Please enter all required fields: Phone " );
    } else if (!regexp_28230.test(form.ap_field_28230.value)){
      form.ap_field_28230.focus();
      form.ap_field_28230.select();
      alert( "Please correct required field: Phone" );
    } else if (form.ap_field_28227.value === ""){
      alert( "Please enter all required fields: Email " );
    } else if (!regexp_28227.test(form.ap_field_28227.value)){
      form.ap_field_28227.focus();
      form.ap_field_28227.select();
      alert( "Please correct required field: Email" );
    } else {
      document.ap_form_2758.submit();
    }
 }

function showForm(){
var formHTML = '<div style="width:500px; background: #eee; border: dotted 1px #ccc; display:block; float:left; padding:5px;">       <div style="width:95%; float:left; clear:both;">            <span style="font: bold 1.5em helvetica;">GET HELP WITH YOUR ALCOHOL OR DRUG REHAB NOW!</span>       </div>       <div style="width:95%;float:left; clear:both;margin:0px 0px 7px 0px;">            <span style="font: bold 1.25em helvetica;">For additional Information, please contact us at the phone number listed above,or simply fill out the form below and one of our caring  Counselors will call you back ASAP</span>       </div>  <form name="ap_form_2758" ID="ap_form_2758" method="post" action="https://www.aimcrm.com/remote/form_post.php" enctype="multipart/form-data"><input type="hidden" name="action" value="feedback_visitor_add"><input type="hidden" name="org_id" value="633"><input type="hidden" name="f_id" value="2758"><div style="width:95%; float:left; clear:both;margin:  0px 0px 3px 0px;">            <span style="width:35%; float:left;margin: 0px 0px 0px 5px; ">                 <span style=" font-weight:bold;float: left;">Contact Name<span style="font-size:7pt;color:red;">*</span></span>                 <span style=" font:italic helvetica smaller normal; float: left;"></span>            </span>            <span style="width:60%; float:left;"><input type="text" id="ap_field_28325" name="ap_field_28325" value="" style="" /></span>       </div>  <div style="width:95%; float:left; clear:both;margin:  0px 0px 3px 0px;">            <span style="width:35%; float:left;margin: 0px 0px 0px 5px; ">                 <span style=" font-weight:bold;float: left;">Phone<span style="font-size:7pt;color:red;">*</span></span>                 <span style=" font:italic helvetica smaller normal; float: left;"></span>            </span>            <span style="width:60%; float:left;"><input type="text" id="ap_field_28230" name="ap_field_28230" value="" style="" /></span>       </div>  <div style="width:95%; float:left; clear:both;margin:  0px 0px 3px 0px;">            <span style="width:35%; float:left;margin: 0px 0px 0px 5px; ">                 <span style=" font-weight:bold;float: left;">Email<span style="font-size:7pt;color:red;">*</span></span>                 <span style=" font:italic helvetica smaller normal; float: left;"></span>            </span>            <span style="width:60%; float:left;"><input type="text" id="ap_field_28227" name="ap_field_28227" value="" style="" /></span>       </div>  <div style="width:95%; float:left; clear:both;margin:  0px 0px 3px 0px;">            <span style="width:35%; float:left;margin: 0px 0px 0px 5px; ">                 <span style=" font-weight:bold;float: left;">Other Info</span>                 <span style=" font:italic helvetica smaller normal; float: left;"></span>            </span>            <span style="width:60%; float:left;"><textarea id="ap_field_28327" name="ap_field_28327" style=""></textarea></span>       </div>  <div>            <span><input name="Submit" type="button" value="Submit" onclick="ap_validate_2758()"><p><span style="font-size:8pt;color:red;">* Required Field</span><a href="http://www.aimcrm.com" style="text-decoration:none;border:none;" title="lead management"><div style="font-size:8pt;color:black;"><img border="0" src="http://www.aimcrm.com/images/ssl_lock.gif" align="ABSBOTTOM" alt="Click to learn more.">Secure Form by <img border="0" src="http://www.aimcrm.com/images/aimpromote_tiny_icon.gif" align="ABSBOTTOM" alt="Click to learn more."></div></a></p></span>       </div>  </div></form>';
if(!formShown){
     document.writeln(formHTML);
}
formShown=true;
}
var formShown = false;
showForm();