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CONFIDENTIAL REFERRAL FORM
REFERRAL SOURCE INFORMATION
Referrer Name
*
First Name
Last Name
Referrer Email
example@example.com
Agency/Company
*
Referrer Phone Number
*
Please enter a valid phone number.
Referrer Fax Number
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PATIENT INFORMATION
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Age
Sex
*
Address
*
City
*
State
*
Zip
*
Patient Phone Number
*
Please enter a valid phone number.
Patient Email
example@example.com
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INSURANCE INFORMATION
Compassion Community Care is an in-network Provider with the insurance plans listed in the drop down below. If your plan is not listed, we also operate on a Sliding Scale Fee and can take into account family size and income for services at a cost tailored for you. We are flexible with monthly, bi-weekly, or weekly payment plans for any patients. With questions regarding insurance or the Sliding Scale Application process, we will gladly assist you at (725)-696-9982.
Insurance Company
*
Please Select
Anthem Nevada Medicaid
HPN Nevada Medicaid
Silver Summit Healthplan Medicaid
Molina Medicaid
Medicare Part B
BlueCross BlueShield PPO
Group Number
ID Number
*
Name of Insured
*
Relationship to Insured
(Options include: Self, Spouse, Parent, Referrer)
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CLINICAL INFORMATION
Primary Diagnosis
*
Secondary Diagnosis
Problem List: (CHECK ALL THAT APPLY)
*
Alcohol Use D/O
Amphetamine Use D/O
Anger
Anxiety
Chronic Relapse
Depression
Disordered Eating
Family Conflict
Grief/Loss
Mood Instability
Opioid Use D/O
Personality Disorder
Relationship Conflict
SMI and/or Psychosis
Sedative Use D/O
Self-Harm
Sex/Porn Addiction
Suicidality
Other
Type of Service
*
Individual Therapy
Couples Therapy
Family Therapy
Primary Care
Psychiatric Evaluation
Medication Management
Neurofeedback
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REFERRING TO:
Therapy - 9748 Gilespie Street Suite 330 Location
Therapy - 7373 Peak Dr Suite 130 Location
Primary Care/Psychiatric Services
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