2. 
3. LYON COUNTY HUMAN SERVICES

   620 Lake Avenue Silver Springs, Nevada 89429  

   Phone: (775) 577-5009 Fax: (775) 577-5093

7. First Name*
8. Last Name*
9. Date of Birth*
   Date of Birth
11. Address1*
13. City*
14. State*
15. Zip
17. Phone Number
18. Email Address
20. Race
    -- Select One --American Indian or Alaskan NativeAsianBlack or African-AmericanNative Hawaiian or Other Pacific IslanderWhite/CaucasianMultipleDeclined to SpecifyUnknown
21. Ethnicity
    -- Select One --Hispanic / LatinoNon-Hispanic / Non-LatinoDon't KnowDeclined to Specify
22. Gender Identity
    -- Select One --MaleFemaleTrans-MaleTrans-FemaleNon-binaryGender FluidQuestioningChoose Not to DiscloseOtherA gender other than singularly female or male (e.g., non-binary, genderfluid, agender, culturally specific gender)TransgenderClient doesn't knowClient refused
24. Please check assistance anyone in the household is receiving

    1. SNAP
    2. TANF
    3. EAP
    4. Medicaid
    5. Medicare
    6. Kinship Care
    7. Nevada Check-Up
25. Please check which housing situation best describes the household

    1. Literally Homeless
    2. Chronically Homeless
    3. Shelter
    4. Apartment
    5. Renting a room
    6. With Family
    7. With Friends
    8. Foster Care
    9. Hospital
    10. Incarcerated
    11. Assisted Living
    12. Group Home
    13. Transitional Housing
    14. Own Home
    15. Rent Home
    16. Motel/Hotel
    17. Transient
    18. Unknown
    19. Other
26. What is the annual household income

    1. $0 - $10,000
    2. $10,000 - $20,000
    3. $20,000 - $30,000
    4. $30,000 - $40,000
    5. $40,000 - $50,000
    6. $50,000 +
30. Household Member Information
32. 1. Household Member Name
33. 1. Relationship to Client
    -- Select One --SpouseParentChildSiblingGrandparentGuardianCaregiverRoommateOther
34. 1. Date of Birth
    1. Date of Birth
36. 1. Race
    -- Select One --American Indian or Alaskan NativeAsianBlack or African-AmericanNative Hawaiian or Other Pacific IslanderWhite/CaucasianMultipleDeclined to SpecifyUnknown
37. 1. Ethnicity
    -- Select One --Hispanic / LatinoNon-Hispanic / Non-LatinoDon't KnowDeclined to Specify
38. 1. Gender Identity
    -- Select One --MaleFemaleTrans-MaleTrans-FemaleNon-binaryGender FluidQuestioningChoose Not to DiscloseOtherA gender other than singularly female or male (e.g., non-binary, genderfluid, agender, culturally specific gender)TransgenderClient doesn't knowClient refusedData not collected
42. 2. Household Member Name
43. 2. Relationship to Client
    -- Select One --SpouseParentChildSiblingGrandparentGuardianCaregiverRoommateOther
44. 2. Date of Birth
    2. Date of Birth
46. 2. Race
    -- Select One --American Indian or Alaskan NativeAsianBlack or African-AmericanNative Hawaiian or Other Pacific IslanderWhite/CaucasianMultipleDeclined to SpecifyUnknown
47. 2. Ethnicity
    -- Select One --Hispanic / LatinoNon-Hispanic / Non-LatinoDon't KnowDeclined to Specify
48. 2. Gender Identity
    -- Select One --MaleFemaleTrans-MaleTrans-FemaleNon-binaryGender FluidQuestioningChoose Not to DiscloseOtherA gender other than singularly female or male (e.g., non-binary, genderfluid, agender, culturally specific gender)TransgenderClient doesn't knowClient refusedData not collected
52. 3. Household Member Name
53. 3. Relationship to Client
    -- Select One --SpouseParentChildSiblingGrandparentGuardianCaregiverRoommateOther
54. 3. Date of Birth
    3. Date of Birth
56. 3. Race
    -- Select One --American Indian or Alaskan NativeAsianBlack or African-AmericanNative Hawaiian or Other Pacific IslanderWhite/CaucasianMultipleDeclined to SpecifyUnknown
57. 3. Ethnicity
    -- Select One --Hispanic / LatinoNon-Hispanic / Non-LatinoDon't KnowDeclined to Specify
58. 3. Gender Identity
    -- Select One --MaleFemaleTrans-MaleTrans-FemaleNon-binaryGender FluidQuestioningChoose Not to DiscloseOtherA gender other than singularly female or male (e.g., non-binary, genderfluid, agender, culturally specific gender)TransgenderClient doesn't knowClient refusedData not collected
62. 4. Household Member Name
63. 4. Relationship to Client
    -- Select One --SpouseParentChildSiblingGrandparentGuardianCaregiverRoommateOther
64. 4. Date of Birth
    4. Date of Birth
66. 4. Race
    -- Select One --American Indian or Alaskan NativeAsianBlack or African-AmericanNative Hawaiian or Other Pacific IslanderWhite/CaucasianMultipleDeclined to SpecifyUnknown
67. 4. Ethnicity
    -- Select One --Hispanic / LatinoNon-Hispanic / Non-LatinoDon't KnowDeclined to Specify
68. 4. Gender Identity
    -- Select One --MaleFemaleTrans-MaleTrans-FemaleNon-binaryGender FluidQuestioningChoose Not to DiscloseOtherA gender other than singularly female or male (e.g., non-binary, genderfluid, agender, culturally specific gender)TransgenderClient doesn't knowClient refusedData not collected
72. 5. Household Member Name
73. 5. Relationship to Client
    -- Select One --SpouseParentChildSiblingGrandparentGuardianCaregiverRoommateOther
74. 5. Date of Birth
    5. Date of Birth
76. 5. Race
    -- Select One --American Indian or Alaskan NativeAsianBlack or African-AmericanNative Hawaiian or Other Pacific IslanderWhite/CaucasianMultipleDeclined to SpecifyUnknown
77. 5. Ethnicity
    -- Select One --Hispanic / LatinoNon-Hispanic / Non-LatinoDon't KnowDeclined to Specify
78. 5. Gender Identity
    -- Select One --MaleFemaleTrans-MaleTrans-FemaleNon-binaryGender FluidQuestioningChoose Not to DiscloseOtherA gender other than singularly female or male (e.g., non-binary, genderfluid, agender, culturally specific gender)TransgenderClient doesn't knowClient refusedData not collected
80. If you need to add additional household members, please include them in the text box provided below.
82. Additional Household Member Information
86. Please provide a brief explanation of the most immediate needs for the household. *If requesting cremation assistance please provide the decedent's name and age in this field. *

    Please do not include social security numbers or protected information.

88. Lyon County Human Services will typically respond within 5 business days. If you have a more immediate need, please call (775) 577-5009.

92. Agency Name

    Please provide the name of the agency making the referral

93. Name of Individual Providing Referral

    Please provide the name of the person within the agency making the referral.

95. Agency Phone Number
96. Agency Email Address
Leave This Blank:


98. 1. Receive an email copy of this form.
99. Email address

    This field is not part of the form submission.

100. Submit Submit and Print

* indicates a required field