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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

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What Is Your Name?* This field is required.

First Name

Last Name

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What Is Your Date of Birth?* This field is required.

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Please enter your email address:* This field is required.

5

Please enter your phone number:* This field is required.

Please enter a valid phone number.

6

Can we send text messages to that phone number?* This field is required.

YESNO

7

Which school or university do you attend?* This field is required.

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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.

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{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

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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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Have you used drugs other than those required for medical reasons?* This field is required.

YESNO

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Do you use more than one drug at a time?* This field is required.

YESNO

15

Are you always able to stop using drugs when you want to?* This field is required.

YESNO

16

Have you had "blackouts" or "flashbacks" as a result of drug use?* This field is required.

YESNO

17

Do you ever feel bad or guilty about your drug use?* This field is required.

YESNO

18

Does your spouse (or parents) ever complain about your involvement with drugs?* This field is required.

YESNO

19

Have you neglected your family because of your use of drugs?* This field is required.

YESNO

20

Have you engaged in illegal activities in order to obtain drugs?* This field is required.

YESNO

21

Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?* This field is required.

YESNO

22

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

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{name:first}'s DAST-10 Score

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Do you currently use alcohol?

YESNO

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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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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

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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

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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

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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

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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

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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

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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

33

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

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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

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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

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{name:first}'s AUDIT Score

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Do you currently use tobacco/nicotine products?(cigarettes, vape, other nicotine or tobacco products)

YESNO

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Would you like to discuss reducing or stopping tobacco and nicotine use?

YESNO

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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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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

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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

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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

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How many cigarettes do you smoke each day?* This field is required.

10 or fewer

11 to 20

21 to 30

31 or more

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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

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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

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{name:first}'s Fagerström Test for Nicotine Dependence Score

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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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{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

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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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Little interest or pleasure in doing things* This field is required.

Not at all

Several days

More than half the days

Nearly every day

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Feeling down, depressed, or hopeless* This field is required.

Not at all

Several days

More than half the days

Nearly every day

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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

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Feeling tired or having little energy* This field is required.

Not at all

Several days

More than half the days

Nearly every day

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Poor appetite or overeating* This field is required.

Not at all

Several days

More than half the days

Nearly every day

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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

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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

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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

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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

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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

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{name:first}'s PHQ-9 score

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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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Feeling nervous, anxious, or on edge?* This field is required.

Not at all

Several Days

More than half the days

Nearly every day

63

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

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Worrying too much about different things?* This field is required.

Not at all

Several Days

More than half the days

Nearly every day

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Had trouble relaxing?* This field is required.

Not at all

Several Days

More than half the days

Nearly every day

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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

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Becoming easily annoyed or irritable?* This field is required.

Not at all

Several Days

More than half the days

Nearly every day

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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

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{name:first}'s GAD-7 score

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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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Would you like to upload images of your insurance card so that our case managers have this information on file?* This field is required.

YESNO

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Take picture of the front of your insurance card* This field is required.

73

Take picture of the back of your insurance card* This field is required.

74

Submission Date

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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.