Start

1

What State Do You Live In?* This field is required.

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

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

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.

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.

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 case managers 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

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 case manager 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 case managers 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 case manager to determine if treatment is right for you.

88

Would you like to upload images of your insurance card so that our case managers 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

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.