Start

This assessment helps us determine if PursueCare virtual care is right for you and how to start treatment. It takes about 5 to 7 minutes.

If you are in immediate danger, feeling unsafe, or having thoughts of self-harm, do not complete this assessment.
Call 911 or go to the nearest emergency room now.

I need urgent help now

Where are you right now?(Required)

Finding out what state you are in helps us determine if services are available where you live.

We are sorry but services are not yet available in your location at this time.

We can notify you when services become available if you fill out your contact information below.

What Is Your Name(Required)

First Last

What Is Your Email(Required)

What Is Your Phone Number

Are you at least 18 years of age?(Required)

Yes

We are sorry but treatment is only available for individuals 18 years of age or older at this time.

Return to homepage

What brings you to PursueCare (please select all that apply)(Required)

Help with alcohol use

Help with opioids

Help with stimulants

Not sure, I want to talk to someone about it.

It’s a courageous step to reach out for help with a substance use disorder and there is real reason for hope.

A nationally representative survey estimated that 11.1% of U.S. adults (≈ 27.5 million) reported having had a substance-use problem in their lifetime, and of those, about 74.8% (≈ 20.5 million) reported they were in recovery or had recovered.

What this means: You are absolutely not alone. Many others have had challenges and succeeded in building a new life.

Recovery Is Possible

We are going to ask some questions based on your responses so far that will better help us get you started on the path to recovery.

Over the last two weeks, how often have you been bothered by the following problems?

Little interest or pleasure in doing things(Required)

Not at all

Several days

More than half of the days

Nearly every day

Feeling down, depressed, or hopeless(Required)

Not at all

Several days

More than half of the days

Nearly every day

Over the last two weeks, how often have you been bothered by the following problems?

Feeling nervous, anxious, or on edge(Required)

Not at all

Several days

More than half of the days

Nearly every day

Not being able to stop or control worrying(Required)

Not at all

Several days

More than half of the days

Nearly every day

In the past 2 weeks, have you had thoughts of harming yourself or that you would be better off dead?(Required)

Yes

Are you safe where you are right now?(Required)

Yes

PursueCare does not offer emergency services!

If you are in immediate danger, feeling unsafe, or having thoughts of self-harm, do not complete this assessment.
Call 911 or go to the nearest emergency room now.

If you need to talk, the 988 Lifeline is also available to call right now.

At the 988 Suicide & Crisis Lifeline, we understand that life’s challenges can sometimes be difficult. Whether you’re facing mental health struggles, emotional distress, alcohol or drug use concerns, or just need someone to talk to, our caring counselors are here for you. You are not alone.

The following questions are being asked because you selected you were interested in help with alcohol use.

How often do you have a drink containing alcohol?(Required)

Never

Monthly or less

2 to 4 times per month

2 to 3 times per week

4 or more times per week

How many standard drinks on a typical day when you are drinking?(Required)

0, 1, or 2

3 or 4

5 or 6

7 – 9

10 or more

How often do you have six or more drinks on one occasion?(Required)

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

When was your last drink?(Required)

Today

Yesterday

2 to 7 days ago

8 to 30 days ago

More than 30 days ago

I am not currently drinking

On the heaviest day in the past 2 weeks, about how many drinks did you have?(Required)

Please enter a number greater than or equal to 0.

Have you ever had seizures, delirium tremens, or required medical detox due to alcohol withdrawal?(Required)

Yes

Do you drink daily or near daily most weeks?(Required)

Yes

Do you drink within an hour of waking to avoid feeling ill or shaky?(Required)

Yes

Do you have serious medical conditions that could make withdrawal riskier, such as severe liver disease, heart problems, or pregnancy?(Required)

Yes

Please select any prior treatments for alcohol you have tried (select all that apply)(Required)

Counseling or therapy

Medications such as naltrexone or acamprosate

Inpatient or residential

None of the above

What are your treatment goals?(Required)

Cut back drinking

Stop drinking

Not sure

The following questions are being asked because you selected you were interested in help with opioid use.

Which opioids have you used in the past 30 days? (check all that apply)(Required)

Heroin

Fentanyl

Prescription pain pills without a prescription

Prescription pain pills as prescribed but I feel dependent

Methadone

Buprenorphine

Other

When was your last opioid use?(Required)

Today

Yesterday

2 to 7 days ago

8 to 30 days ago

More than 30 days ago

I am not currently using

Are you currently taking buprenorphine or methadone?(Required)

Yes, I’m taking buprenorphine

Yes, I’m taking methadone

if yes, what is your daily dose and last dose time?(Required)

Think about your opioid use symptoms over the last 12 months and answer the following yes/no question about how you’ve been affected.

Often take more or longer than intended(Required)

Yes

Persistent desire or unsuccessful efforts to cut down(Required)

Yes

A lot of time spent obtaining or using opioids or recovering(Required)

Yes

Craving(Required)

Yes

Role obligations affected at work, school, or home(Required)

Yes

Social or interpersonal problems(Required)

Yes

Important activities given up or reduced(Required)

Yes

Use in physically hazardous situations(Required)

Yes

Continued use despite physical or psychological problems(Required)

Yes

Tolerance(Required)

Yes

Withdrawal(Required)

Yes

Have you ever overdosed?(Required)

Yes

What was the month and year of your overdose, if known?

Do you have naloxone available?(Required)

Yes

What is your interest in medication for opioid use disorder treatment?(Required)

Buprenorphine treatment

I am not sure, please discuss options

I prefer counseling only

The following questions are being asked because you selected you were interested in help with stimulant use.

Which stimulants have you used in the past 30 days? (select all that apply)(Required)

Cocaine

Methamphetamine

Prescription stimulants without a prescription

Prescription stimulants as prescribed but I feel dependent

Other

If other:(Required)

When was your last stimulant use?(Required)

Today

Yesterday

2 to 7 days ago

8 to 30 days ago

More than 30 days ago

I am not currently using

In the past 3 months, how often have you used stimulants?(Required)

Never

Once or twice

Monthly

Weekly

Daily or almost daily

Has anyone expressed concern about your stimulant use?(Required)

Yes, in the past 3 months

Yes, but not in the past 3 months

Have you tried and failed to cut down in the past 3 months?(Required)

Yes

General Medical History

Are you currently taking any medications? (any kind, even over the counter medicines)(Required)

Yes

Please list the current medications you are taking.(Required)

Try to include type and frequency. (example – “blood thinners,” “seizure medicines,” “liver disease medicines,” “benzodiazepines,” “sleep medicines.” Daily, weekly, as-needed)

Are you allergic to any medicines?(Required)

Yes

If yes, please list what medications you are allergic to:(Required)

Please select if any of the following medical conditions apply to you. (select all that may apply)(Required)

Severe liver disease

Kidney disease

Heart rhythm problems

Seizure disorder

Pregnancy or trying to become pregnant

Breastfeeding

None of the above

Have you ever been told you have cirrhosis or severe liver disease?(Required)

Yes

Are you taking benzodiazepines such as alprazolam, clonazepam, diazepam, or temazepam?(Required)

Yes

Have you used tobacco or nicotine products in the past 30 days?(Required)

Yes

Have you used cannabis in the past 30 days?(Required)

Yes

List other substances you want help with:

Do you currently have or suspect that you have a sexually transmitted infection?(Required)

Yes

I’m not sure

Have you been diagnosed with Hepatitis C?(Required)

Yes

I’m not sure

Have you been diagnosed with HIV?(Required)

Yes

I’m not sure

Please tell us about yourself

We will use this information to be able to contact you about getting started with services.

Your Name(Required)

First Last

Email(Required)

Mobile Phone Number(Required)

Do we have permission to text you messages?(Required)

Yes

If yes, you agree to our SMS Terms of Service

Preferred contact method:(Required)

Text message

Phone call

Best time to reach you:(Required)

Morning

Afternoon

Evening

What is your date of birth?(Required)

MM slash DD slash YYYY

Sex assigned at birth:(Required)

Female

Male

Nonbinary

Prefer to self describe

Prefer not to say

What gender do you identify as?(Required)

Female

Male

Nonbinary

Prefer to self describe

Prefer not to say

Primary language:(Required)

English

Spanish

Other

If other:(Required)

Are you an active member of the U.S. Armed Forces or a Veteran?(Required)

Yes

Coverage selection and payment

We accept many private insurances, as well as Medicare and Medicaid. If we’re not in-network with your private health plan, we can help you submit your claim for reimbursement. Our case managers will help you determine whether your treatment is covered.

Patients with a Commercial plan should expect copay and/or coinsurance as well as any additional payment requirement which would include if your deductible has been met.

We also accept all major US credit cards and pre-paid debit cards for patients who would like to pay directly for services.

How would you like to pay for care?(Required)

Use my health insurance

Pay directly with our self-pay monthly plan starting at as low as $99 per month

(Paying directly does not require a credit card to be entered into this form right now.)

PursueCare Bills Your Insurance Directly

If you would like to use your insurance for payment we can help see if you are eligible with the coverage you have.

Note – Patients with a Commercial plan should expect copay and/or coinsurance as well as any additional payment requirement which would include if your deductible has been met.

How would you like to submit your insurance information?(Required)

Upload pictures of my insurance card to the PursueCare team

Enter my insurance information manually

Upload images of the FRONT AND BACK of your insurance card(Required)

Drop files here or

Max. file size: 50 MB, Max. files: 2.

You’ll be able to crop the images after uploading or taking a picture with your phone.

Do you consent to a real-time eligibility and benefits check and to contact your plan if needed to confirm coverage and prior authorization?(Required)

Yes, I consent to a real-time eligibility and benefits check and to contact your plan if needed to confirm coverage and prior authorization

Insurance company name(Required)

Member ID(Required)

Group Number (optional)

Policy Holder Name(Required)

First Last

Policy Holder Date of Birth

MM slash DD slash YYYY

Do you consent to a real-time eligibility and benefits check and to contact your plan if needed to confirm coverage and prior authorization?(Required)

Yes, I consent to a real-time eligibility and benefits check and to contact your plan if needed to confirm coverage and prior authorization

Pay directly for services

Treatment always starts with a new patient evaluation to make sure you are enrolled in the correct program. This evaluation costs $50 (a one-time fee) and will be collected when you discuss scheduling your evaluation with our Patient Access Specialist.

If treatment is right for you, we have plans starting as low as $99/month* that you can discuss with our team.

* The cost of any medications prescribed is not included in the cost of monthly services. Any medications prescribed are an additional fee that the pharmacy would collect.

Whether you are enrolled with PursueCare services or not, PursueCareRx can fill all of your SUD/MAT prescriptions, other supportive medications, and any other prescriptions you may have. We work with your prescribing clinicians to make the process as easy as possible. All your medication can be shipped directly to your door.

Electronic prescription submission and direct home delivery offer the highest level of confidentiality and convenience.

What is your pharmacy preference?(Required)

I’m interested in using PursueCareRx

Use my local pharmacy

Local pharmacy name:(Required)

Local pharmacy city, state and zip code:(Required)

City State ZIP Code

Thank you for filling out this form.

You will be able to submit the form to us on the next page.

Once submitted it will send our team what you’ve filled out and will prompt you to download our mobile app and create an account – please do this at your earliest convenience.

One of our Patient Access Specialists will be reaching out to follow up with you about your interest in starting services.