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1
What State Do You Live In?* This field is required.
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
2
Are You Over 18 Years Old?* This field is required.
YESNO
3
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.
4
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.
5
Your Name* This field is required.
6
Your Email Address* This field is required.
7
Your Phone Number (optional)
Please enter a valid phone number.
8
When Do You Turn 18 years old?* This field is required.
Date
Month
Day
Year
9
Tell Us Why You're Here:* This field is required.Please select all that apply
I would like to get help with substance use disorder
I am interested in mental health services
I was referred by a healthcare provider
I have a friend/family member living with substance use disorder
I am curious about PursueCare and would like to learn more
10
What Is Your Name?* This field is required.
First Name
Last Name
11
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.
12
What Is Your Date of Birth?* This field is required.
Date
Month
Day
Year
13
Please enter your email address:* This field is required.
14
Please enter your phone number:* This field is required.
Please enter a valid phone number.
15
Can we send text messages to that phone number?* This field is required.
YESNO
16
How Did You Hear About PursueCare?* This field is required.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.
Please Select
Please Select
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
17
Which hospital were you referred from?* This field is required.
18
Which primary care provider were you referred from?* This field is required.
19
Which addiction treatment facility were you referred from?* This field is required.
20
Which health care provider were you referred from?* This field is required.
21
Who is your employer?* This field is required.
22
Which health plan referred you?* This field is required.
Select
Select
Aetna
Anthem
BlueCross/BlueShield
CareSource
Cigna
Humana
Molina
Highmark
UniCare
UnitedHealthcare
WellCare
Other
23
If other, which health plan referred you?
24
Which school or university referred you?* This field is required.
25
If other, where did you hear about PursueCare?* This field is required.
26
{name:first}, you mentioned you would like to get help with substance use. Are you interested in providing more information about your substance use history so that our care coordinators can learn more about your specific needs? Any information you provide is strictly confidential, secure, and never shared with anyone other than your care team.
YESNO
27
Are you currently using any of the following drugs?* This field is required.Choose all that apply
Opioids (Pain pills, heroin, fentanyl)
Stimulants (Cocaine, Methamphetamine/Crystal)
Benzodiazepines (Benzos, Downers, Valium, Ativan, Xanax)
Sleeping Pills (Ambien, Lunesta, Sonata)
Marijuana (Cannabis)
Kratom
Hallucinogens (Psilocybin/mushrooms, LSD, ketamine, PCP)
MDMA (Ecstasy/Molly)
Amyl Nitrate or Butyl Nitrate (Poppers)
28
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.
29
These questions refer to the past 12 months.
30
Have you used drugs other than those required for medical reasons?* This field is required.
YESNO
31
Do you use more than one drug at a time?* This field is required.
YESNO
32
Are you always able to stop using drugs when you want to?* This field is required.
YESNO
33
Have you had "blackouts" or "flashbacks" as a result of drug use?* This field is required.
YESNO
34
Do you ever feel bad or guilty about your drug use?* This field is required.
YESNO
35
Does your spouse (or parents) ever complain about your involvement with drugs?* This field is required.
YESNO
36
Have you neglected your family because of your use of drugs?* This field is required.
YESNO
37
Have you engaged in illegal activities in order to obtain drugs?* This field is required.
YESNO
38
Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?* This field is required.
YESNO
39
Have you had medical problems as a result of your drug use (e.g. memory loss, hepatitis, convulsions, bleeding, etc.)?* This field is required.
YESNO
40
{name:first}'s DAST-10 Score
41
Do you currently use alcohol?
YESNO
42
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.
43
How often do you have a drink containing alcohol?* This field is required.
Never
Monthly or less
2-4 times a month
2-3 times a week
4 or more times a week
44
How many standard drinks containing alcohol do you have on a typical day when drinking?* This field is required.
1 or 2
3 or 4
5 or 6
7 to 9
10 or more
45
How often do you have six or more drinks on one occasion?* This field is required.
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
46
During the past year, how often have you found that you were not able to stop drinking once you had started?* This field is required.
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
47
During the past year, how often have you failed to do what was normally expected of you because of drinking?* This field is required.
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
48
During the past year, how often have you needed a drink in the morning to get yourself going after a heavy drinking session?* This field is required.
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
49
During the past year, how often have you had a feeling of guilt or remorse after drinking?* This field is required.
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
50
During the past year, how often have you been unable to remember what happened the night before because you had been drinking?* This field is required.
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
51
Have you or someone else been injured as a result of your drinking?* This field is required.
No
Yes, but not in the past year
Yes, during the past year
52
Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested you cut down?* This field is required.
No
Yes, but not in the past year
Yes, during the past year
53
{name:first}'s AUDIT Score
54
Do you currently use tobacco/nicotine products?(cigarettes, vape, other nicotine or tobacco products)
YESNO
55
Would you like to discuss reducing or stopping tobacco and nicotine use?
YESNO
56
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.
57
How soon after you wake up do you smoke your first cigarette?* This field is required.
Within 5 minutes
5 to 30 minutes
31 to 60 minutes
After 60 minutes
58
Do you find it difficult not to smoke in places where you shouldn't, such as in church or school, in a movie, at the library, on a bus, in court or in a hospital?* This field is required.
Yes
No
59
Which cigarette would you most hate to give up; which cigarette do you treasure the most?* This field is required.
The first one in the morning
Any other one
60
How many cigarettes do you smoke each day?* This field is required.
10 or fewer
11 to 20
21 to 30
31 or more
61
Do you smoke more during the first few hours after waking up than during the rest of the day?* This field is required.
Yes
No
62
Do you still smoke if you are so sick that are in bed most of the day, or if you have a cold or the flu and have trouble breathing?* This field is required.
Yes
No
63
{name:first}'s Fagerström Test for Nicotine Dependence Score
64
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 care coordinator to determine if treatment is right for you.
65
{name:first}, you mentioned you are interested in mental health services. Are you willing to provide more information so that our care coordinators can learn more about your specific mental health needs? Any information you provide is strictly confidential, secure, and never shared with anyone other than your care team.
YESNO
66
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?
67
Little interest or pleasure in doing things* This field is required.
Not at all
Several days
More than half the days
Nearly every day
68
Feeling down, depressed, or hopeless* This field is required.
Not at all
Several days
More than half the days
Nearly every day
69
Trouble falling or staying asleep, or sleeping too much* This field is required.
Not at all
Several days
More than half the days
Nearly every day
70
Feeling tired or having little energy* This field is required.
Not at all
Several days
More than half the days
Nearly every day
71
Poor appetite or overeating* This field is required.
Not at all
Several days
More than half the days
Nearly every day
72
Feeling bad about yourself or that you are a failure or have let yourself or your family down* This field is required.
Not at all
Several days
More than half the days
Nearly every day
73
Trouble concentrating on things, such as reading the newspaper or watching television* This field is required.
Not at all
Several days
More than half the days
Nearly every day
74
Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual* This field is required.
Not at all
Several days
More than half the days
Nearly every day
75
Thoughts that you would be better off dead, or of hurting yourself* This field is required.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.
Not at all
Several days
More than half the days
Nearly every day
76
How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?* This field is required.
Not difficult at all
Somewhat difficult
Very difficult
Extremely Difficult
77
{name:first}'s PHQ-9 score
78
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?
79
Feeling nervous, anxious, or on edge?* This field is required.
Not at all
Several Days
More than half the days
Nearly every day
80
Not being able to stop or control worrying?* This field is required.
Not at all
Several Days
More than half the days
Nearly every day
81
Worrying too much about different things?* This field is required.
Not at all
Several Days
More than half the days
Nearly every day
82
Had trouble relaxing?* This field is required.
Not at all
Several Days
More than half the days
Nearly every day
83
Being so restless that it's hard to sit still?* This field is required.
Not at all
Several Days
More than half the days
Nearly every day
84
Becoming easily annoyed or irritable?* This field is required.
Not at all
Several Days
More than half the days
Nearly every day
85
Feeling afraid as if something awful might happen?* This field is required.
Not at all
Several Days
More than half the days
Nearly every day
86
{name:first}'s GAD-7 score
87
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 care coordinator to determine if treatment is right for you.
88
Would you like to upload images of your insurance card so that our care coordinators can check your insurance eligibility?* This field is required.
YESNO
89
Take picture of the front of your insurance card* This field is required.
90
Take picture of the back of your insurance card* This field is required.
91
Submission Date
Submission Date
Month
Day
Year
92
{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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