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Welcome to Compassion Community Care!
We are excited to take this journey with you!
Let's get some basic client information down first.
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PATIENT INFORMATION
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Age
Sex
*
Race
*
Ethnicity
*
Address
*
City
*
State
*
Zip
*
Patient Phone Number
*
Please enter a valid phone number.
Patient Email
*
example@example.com
Upload Photo of Front of Driver's License/Nevada ID
*
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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
Sierra Health and Life (SHL) Fully Insured PPO
Sierra Healthcare Options (SHO) PPO
Self Pay
Group Number
*
ID Number
*
Name of Insured
*
Relationship to Insured
(Options include: Self, Spouse, Parent, Referrer)
Upload Photo of Front of Insurance Card (if no insurance upload paystub)
*
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Drag and drop files here
Choose a file
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of
Upload Photo of Back of Insurance Card (if no insurance upload bank statement)
*
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Drag and drop files here
Choose a file
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CLINICAL INFORMATION
What problems are your experiencing?(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
What type of service are you looking for?
*
Individual Therapy
Couples Therapy
Family Therapy
Primary Care
Psychiatric Evaluation
Medication Management
Neurofeedback
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We offer a wide variety of providers!
Please choose which provider you want based on the service and location of your choice:
Therapy - 9748 Gilespie Street Suite 330 Location
Therapy - 7373 Peak Dr Suite 130 Location
Primary Care/Psychiatric Services - 9748 Gilespie Street Suite 330 Location
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