Candidate Questionnaire

Your Name(Required)
First Last
Your Address(Required)
Street Address City State ZIP Code
COVID-19 Vaccination Status(Required)
*If you are not vaccinated, please contact recruiting@pursuecare.com to discuss options.
Please choose your clinical category (check all that apply):(Required)
- Therapist/Counselor
- MAT Prescriber
- Psych Med Manager
- MD/DO/Physician MAT Prescriber
- Collaborating Physician
- Admissions Counselor
Have you opted out of Medicare/Medicaid?(Required)
- Yes
- No
Licenses and Credentials

Please only submit licensure information for the following states: CT, DE, FL, KY, ME, MD, MA, NH, NJ, OH, PA, and WV.

Therapist/Counselor Licenses and Credentials

What state is this license in?	Professional license type:	License number:	Is the license active or inactive?	Actions

There are no Licenses and Credentials.

Please upload all state licensures(Required)
Drop files here or

Max. file size: 50 MB, Max. files: 5.
Please list any other states that you're licensed in:
What is your comfort with DSM Diagnosis, specifically diagnosing substance use disorders?(Required)
Have you ever been part of an interdisciplinary MAT team?(Required)
What is your experience with telehealth?(Required)
What have been your most valuable clinical experiences and why?(Required)
What roles have you had that you did not enjoy and why?(Required)
What interests you about addiction medicine?(Required)
Are you comfortable practicing independently?(Required)
How do you convey respect to your patients and colleagues?(Required)

MAT Prescriber Licenses and Credentials

What state is this license in?	Professional license type:	License number:	Is the license active or inactive?	Actions

There are no Licenses and Credentials.

Please upload all state licensures(Required)
Drop files here or

Max. file size: 50 MB, Max. files: 5.
Hidden
Please upload all XDEA licenses
Drop files here or

Max. file size: 50 MB, Max. files: 5.
Please upload Federal DEA license (if applicable)
Drop files here or

Max. file size: 50 MB, Max. files: 5.
Please upload State DEA/CSR licenses (if applicable)
Drop files here or

Max. file size: 50 MB, Max. files: 5.
Please upload all Board Certifications(Required)
Drop files here or

Max. file size: 50 MB, Max. files: 5.
Please list any other states that you're licensed in:
Please share your view on harm and risk reduction in Medication Assisted Treatment.(Required)
How do you determine the initial dose of buprenorphine/naloxone for a patient?(Required)
How do you determine how often patients in MAT treatment need to be seen for a medical follow-up appointment?(Required)
Please share what strategies you use to increase patient engagement for a struggling patient in their MAT treatment.(Required)
What has been your experience in prescribing buprenorphine (Subutex)?(Required)
How do you convey respect to your patients and colleagues?(Required)
Do you have experience providing telehealth?(Required)

Psych Med Manager Licenses and Credentials

What state is this license in?	Professional license type:	License number:	Is the license active or inactive?	Actions

There are no Licenses and Credentials.

Please upload all state licensures(Required)
Drop files here or

Max. file size: 50 MB, Max. files: 5.
Please upload Federal DEA license (if applicable)
Drop files here or

Max. file size: 50 MB, Max. files: 5.
Please upload State DEA/CSR licenses (if applicable)
Drop files here or

Max. file size: 50 MB, Max. files: 5.
Please upload all Board Certifications(Required)
Drop files here or

Max. file size: 50 MB, Max. files: 5.
Please list any other states that you're licensed in:
Please share your view/philosophy on prescribing controlled substances?(Required)
How familiar are you with the dual diagnosis population and medication assisted treatment?(Required)
Please share your view on harm and risk reduction in Mental health and Medication Assisted Treatment.(Required)
Do you have experience providing telehealth/tele psych?(Required)
What diagnoses are you most comfortable diagnosing and treating?(Required)
How do you determine how often patients need to be seen for a psych follow-up appointment?(Required)
Please share what strategies you use to increase patient engagement for a struggling patient?(Required)
Are you waivered or interested in becoming waivered?(Required)
How do you convey respect to your patients and colleagues?(Required)

Medical Licenses and Credentials

What state is this license in?	Professional license type:	License number:	Is the license active or inactive?	Actions

There are no Entries.

Please upload all state licensures(Required)
Drop files here or

Max. file size: 50 MB, Max. files: 5.
Please upload Federal DEA license (if applicable)
Drop files here or

Max. file size: 50 MB, Max. files: 5.
Please upload State DEA/CSR licenses (if applicable)
Drop files here or

Max. file size: 50 MB, Max. files: 5.
Are you Board Certified?(Required)
- Yes
- No
What Board are you certified with?(Required)
Please upload all Board Certifications(Required)
Drop files here or

Max. file size: 50 MB, Max. files: 5.
Please list any other states that you're licensed in:
Would you be interested in cross licensing to one of our many states?(Required)
- Yes
- No
Are you a member of the Interstate Medical License Compact (IMLC)?(Required)
- Yes
- No
What is your State of Principal Licensure?(Required)
Please share your view/philosophy on prescribing controlled substances?(Required)
How familiar are you with the dual diagnosis population and medication assisted treatment?(Required)
Please share your view on harm and risk reduction in Mental health and Medication Assisted Treatment.(Required)
Do you have experience providing telehealth/tele psych?(Required)
What diagnoses are you most comfortable diagnosing and treating?(Required)
How do you determine how often patients need to be seen for a psych follow-up appointment?(Required)
Please share what strategies you use to increase patient engagement for a struggling patient?(Required)
How do you convey respect to your patients and colleagues?(Required)

Collaborating Physician Licenses and Credentials

What state is this license in?	Professional license type:	License number:	Is the license active or inactive?	Actions

There are no Licenses and Credentials.

What is your comfort with identifying DSM Diagnosis, specifically identifying substance use disorders?(Required)
Have you ever been part of an interdisciplinary MAT team?(Required)
What have been your most valuable patient interactions and why?(Required)
What is your experience with telehealth?(Required)
What roles have you had that you did not enjoy and why?(Required)
What interests you about addiction medicine?(Required)
What is your experience in doing biopsychosocial assessments and treatment plans?(Required)
Are you comfortable working independently?(Required)
How do you convey respect to your patients and colleagues?(Required)
Are you licensed in any the following states: CT, DE, FL, KY, ME, MD, MA, NH, NJ, OH, PA, and WV.(Required)
- Yes
- No
Please upload all state licensures for CT, DE, FL, KY, ME, MD, MA, NH, NJ, OH, PA, and WV.(Required)
Drop files here or

Max. file size: 8 MB, Max. files: 5.
Please list any other states that you may be licensed in besides CT, DE, FL, KY, ME, MD, MA, NH, NJ, OH, PA, and WV.(Required)
What additional requirements are needed for obtaining you licensure, if any, if applicable.(Required)
Experience / Availability
- How many years of telehealth experience do you have?(Required)
- Please check the days you are available to work:(Required)
  - Sunday
  - Monday
  - Tuesday
  - Wednesday
  - Thursday
  - Friday
  - Saturday
- Times available on Sunday:(Required)
- Times available on Monday:(Required)
- Times available on Tuesday:(Required)
- Times available on Wednesday:(Required)
- Times available on Thursday:(Required)
- Times available on Friday:(Required)
- Times available on Saturday:(Required)
Office Technology
- Computer types you have access to: (check all that apply)(Required)
  - Desktop
  - Laptop – Mac
  - Laptop – PC
  - Tablet or iPad (These are not recommended for providing telehealth services)
- What type of camera do you have for telehealth sessions: (check all that apply)(Required)
  - Internal Camera
  - External Camera
- What is your audio setup for telehealth sessions: (check all that apply)(Required)
  - Internal Mic
  - External Mic
  - Headphones
- Approximately how old is the computer you plan to use for telehealth services:(Required)
- Do you have access to a Printer or Scanner:(Required)
- What Browser(s) do you use: (check all that apply)(Required)
  - Safari
  - Chrome
  - Internet Explorer
  - Edge
  - Firefox
  - Other
- If other:(Required)
Office Setup
- Do you have a Private Office/Space in your home:(Required)
  - Yes
  - No
- Ethernet-Connection Internet Access:(Required)
  - Yes
  - No
- Wireless Internet Access:(Required)
  - Yes
  - No
- White Noise Device:(Required)
  - Yes
  - No
- Download speed reported:(Required)
- Upload speed reported:(Required)
- Click the “RUN SPEED TEST” button below to test your internet connection’s download and upload speed and report the results in the boxes provided.

Candidate Questionnaire

Licenses and Credentials

Experience / Availability

Office Technology

Office Setup