Disclaimer: Any information gathered within this brief questionnaire will be held confidentially, and used or disclosed only for purposes of contacting you, providing treatment , and administration of your health care. Please review the attached Notice of Privacy Practices and click below to acknowledge your understanding and consent to how we use your personal information.

Please select your state from the drop down list below.

We are not actively providing services in your state.

However, during the COVID-19 crisis, we are able to make exceptions under certain circumstances.

Would you like a Care Coordinator to contact you to discuss treatment options with you?

While our specialty is substance use treatment, we are often able to help with other mental health needs.

The questions below are completely optional to answer, but greatly help our Care Coordinators understand your specific treatment needs. Please answer the questions you are comfortable answering below. All answers are confidential and HIPAA secure.

What time would you like a Care Coordinator to reach out to you by phone?

Please select a time during ordinary business hours, including Saturdays.

Please take a moment to download our app by clicking the appropriate button below and then also complete the forms located on the Patient Resources page of the website by Clicking Here.

Download our app

A member or our Care Coordination team will be in touch with you soon. Please complete submitting this form by checking the box below that you agree to PursueCare's Notice of Privacy Practices and click the red "Submit" button.