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PursueCare Patient Sign Up Form
PursueCare Patient Sign Up Form
Fill out this form to send basic information about you to our case managers who will start you on your road to recovery.
New Patient Enrollment Form
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    We are very sorry but PursueCare is not providing services in your state just yet, but we can notify you when we are.

    Fill out the following fields to be notified when we start serving your state.

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    We are very sorry but PursueCare can only provide services to people age 18 and older right now. Fill out the following fields to notify us that you are interested in services and we can reach out when you qualify.

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    Please select all that apply
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    It's great to meet you {name:first}
    PursueCare Can Help

    We offer judgment-free, comprehensive, and convenient virtual care for opioid, alcohol, and other substance use disorders as well as full psychiatry treatment for behavioral health conditions through our mobile app.

    We accept most insurance carriers and also have a low-cost self pay option, but there's absolutely no cost to you right now.

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    Entering who referred you or where you heard about us will help us to better coordinate your care with our health and wellness partners. We will never share your health information without your permission.
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    • Referral from a hospital
    • Referral from my primary care provider
    • Referral from an addiction treatment facility
    • Referral from another health care provider
    • Referral from my employer
    • Referral from my health plan
    • Referral from my school or university
    • Social Media (Facebook, Instagram, Twitter, Reddit)
    • Internet Search (Google search, Google ads, website)
    • Television
    • Family/Friend
    • Returning Patient
    • Other
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    • Aetna
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    • BlueCross/BlueShield
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    • UniCare
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    • Other
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    Choose all that apply
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    The following 10 questions concern information about your possible involvement with drugs not including alcoholic beverages during the past 12 months. Carefully read each statement and decide if your answer is "Yes" or "No" and click the button to make your selection.

    In the statements, "drug use" refers to the use of prescribed or over the counter drugs that may include: cannabis (e.g. marijuana, hash), solvents, tranquillizers (e.g. Valium), barbiturates, cocaine, stimulants (e.g. speed), hallucinogens (e.g. LSD), or narcotics (e.g. heroin). Remember that the questions do not include alcoholic beverages.

    If you have difficulty with a statement, then choose the response that is mostly right.

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    These questions refer to the past 12 months.

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    The AUDIT questionnaire is designed to help in the self-assessment of alcohol consumption and to identify any implications for the person’s health and wellbeing, now and in the future. It consists of 10 questions on alcohol use. The responses to these questions are scored and provide our care team with helpful insight into your alcohol use for treatment and safety.

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    (cigarettes, vape, other nicotine or tobacco products)
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    Patients who try to quit smoking and relapse within two or three weeks usually do so as a result of physical dependence on nicotine. The Fagerström Test for Nicotine Dependence is a standard instrument for assessing the intensity of this physical addiction.

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    Based on your responses, you may benefit from PursueCare's substance use disorder treatment services. We encourage you to complete this form and speak with a case manager to determine if treatment is right for you.

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    The following patient health questionnaire measures how you are feeling to help determine whether you may be experiencing depression, and the possible severity of your symptoms. It also helps us to determine if this form of treatment is right for you.

    Over the last 2 weeks, how often have you been
    bothered by any of the following problems?

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    This question relates to risk for suicide. It is important to understand that we may not review the results of this assessment immediately. If you feel you are at risk, please call 911 at once. For confidential support please contact the National Suicide Prevention Lifeline at 1-800-273-8255.
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    The following patient health questionnaire also measuress how you are feeling to help determine whether you may be experiencing anxiety, and the possible severity of your symptoms. It also helps us to determine if this form of treatment is right for you.

    Over the last 2 weeks, how often have you been
    bothered by any of the following problems?

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    Based on your responses, you may benefit from PursueCare's mental health treatment services. We encourage you to complete this form and speak with a case manager to determine if treatment is right for you.

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    {name:first}, thank you for your interest in our service and for filling out this information. Please finish submitting this form by clicking the "Submit" button below.

    Upon submitting this form you will be redirected to a page where you'll be able to download our app if you haven't done so already - you will also receive a confirmation email.

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