Human Services Online Submission Forms

LYON COUNTY HUMAN SERVICES
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LCHS Provider Referral Form

  1. Lyon County - white background
    HUMAN SERVICES (LCHS)
  2. LCHS PROVIDER REFERRAL FORM
    620 Lake Avenue Silver Springs, Nevada 89429 Phone: (775) 577-5009 Fax: (775) 577-5093 www.lyon-county.org
  3. CLIENT INFORMATION (Head of Household)
  4. OTHER HOUSEHOLD MEMBER'S INFORMATION
    If more than 4 household members, list additional household members in the 'Additional Information' block below.
  5. Other Household Member #1
  6. Other Household Member #2
  7. Other Household Member #3
  8. Other Household Member #4
  9. REASONS FOR CONCERN/REFERRAL
    (Check all that apply)
  10. SENIOR SERVICES
    (age 60 or over)
  11. CHILDREN'S SERVICES
    (Parent/Children)
  12. ADULT SERVICES
    (Individuals/Families)
  13. REFERRING AGENCY INFORMATION
  14. (Point of Contact)
  15. Agency Certification
  16. Lyon County Human Services will typically respond within 5 business days. If you have a more immediate need, please call (775) 577-5009.
  17. Leave This Blank:

  18. This field is not part of the form submission.