LCHS Provider Referral Form

2. 

   HUMAN SERVICES (LCHS)

3. LCHS PROVIDER REFERRAL FORM

   620 Lake Avenue Silver Springs, Nevada 89429 Phone: (775) 577-5009 Fax: (775) 577-5093 www.lyon-county.org

   620 Lake Avenue Silver Springs, Nevada 89429 Phone: (775) 577-5009 Fax: (775) 577-5093 www.lyon-county.org

5. CLIENT INFORMATION (Head of Household)

7. Last Name*

8. First Name*

9. Age*

10. Gender*
    -- Select One --FemaleMaleOtherPrefer not to say

12. Address1*

13. Address2

14. Language(s) spoken*

16. City*

17. State*

18. Zip*

20. Home Phone

21. Cell Phone

22. Message Phone

23. E-mail address

27. OTHER HOUSEHOLD MEMBER'S INFORMATION

    If more than 4 household members, list additional household members in the 'Additional Information' block below.

    If more than 4 household members, list additional household members in the 'Additional Information' block below.

29. Last Name

    Other Household Member #1

30. First Name

31. Relationship to Client
    -- Select One --SpouseMotherFatherDaughterSonSisterBrotherStepmotherStepfatherStepsisterStepbrotherStepdaughterStepsonHalf-sisterHalf-brotherGrandparentGrandchildGrandmotherGrandfatherAdopted ChildAdopted ParentAuntUncleNieceNephewCousinRoommateCaregiverNeighborPartnerOther

32. Age

34. Last Name

    Other Household Member #2

35. First Name

36. Relationship to Client
    -- Select One --SpouseMotherFatherDaughterSonSisterBrotherStepmotherStepfatherStepsisterStepbrotherStepdaughterStepsonGrandparentGrandmotherGrandfatherAuntUncleNieceNephewCousinRoommateCaregiverNeighborPartnerOther

37. Age

39. Last Name

    Other Household Member #3

40. First Name

41. Relationship to Client
    -- Select One --SpouseMotherFatherDaughterSonSisterBrotherStepmotherStepfatherStepdaughterStepsonStepsisterStepbrotherHalf-sisterHalf-brotherGrandparentGrandmotherGrandfatherAuntUncleNieceNephewCousinRoommateCaregiverNeighborPartnerOther

42. Age

44. Last Name

    Other Household Member #4

45. First Name

46. Relationship to Client
    -- Select One --SpouseMotherFatherDaughterSonSisterBrotherStepmotherStepfatherStepdaughterStepsonStepsisterStepbrotherHalf-sisterHalf-brotherGrandparentGrandmotherGrandfatherAuntUncleNieceNephewCousinRoommateCaregiverNeighborPartnerOther

47. Age

51. REASONS FOR CONCERN/REFERRAL

    (Check all that apply)

    (Check all that apply)

53. SENIOR SERVICES

    (age 60 or over)

    1. Non-Emergency Medical Transportation
    2. Senior Center Transportation
    3. Home-Delivered Meals
    4. Socialization
    5. Homemaker Services

    1. Community Resources for Seniors
    2. Senior Center Meals/Nutrition Education
    3. Volunteer Opportunities
    4. Health & Wellness Activities
    5. Other (provide further info below)
55. CHILDREN'S SERVICES

    (Parent/Children)

    1. WIC - Women, Infants and Children
    2. In Home Parent Education
    3. Parenting Classes
    4. In Home Family Support
    5. Cribs for Kids

    1. Early Childhood Development Screenings
    2. Community Resources - Parents/Children
    3. Family and Youth Lifeskills
    4. Child Growth and Development
    5. Other (provide further info below)
57. ADULT SERVICES

    (Individuals/Families)

    1. Application Assistance & Support
    2. Disability Services & Support
    3. Employment/Volunteer Program (Job prep)
    4. Financial Management (Budget, etc)
    5. Housing Stabilization

    1. Re-Entry Services (release from jail/prison)
    2. Community Resources (Individual/family)
    3. Utility Assistance (gas, electric, etc.)
    4. Veteran Assistance (Resources/Referrals)
    5. Other (provide further info below)
59. ADDITIONAL INFORMATION REGARDING FAMILY SITUATION:*

63. REFERRING AGENCY INFORMATION

65. Date of Referral*
    Date of Referral

    Date of Referral

66. Agency Name*

67. Completed by*

    (Point of Contact)

69. Address1*

70. Address2

72. City*

73. State*

74. Zip*

76. Agency Phone Number*

77. Agency Fax Number

78. Agency E-mail

80. Agency Certification

    1. I certify the Family has agreed to receive contact from Lyon County Human Services.

Leave This Blank:


82. 1. Receive email copy
83. Email address

    This field is not part of the form submission.

84. Submit Submit and Print

* indicates a required field