LCHS Referral Form

2. 

   HUMAN SERVICES (LCHS)
3. LCHS REFERRAL FORM

   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

   1. 0-17
   2. 18-59
   3. 60+
   4. Unkown
11. Address1*
12. Address2
13. Language(s) spoken*
15. City*
17. Phone
18. Message Phone
19. E-mail address
23. OTHER HOUSEHOLD MEMBER'S INFORMATION
    If more than 4 household members, list additional household members in the 'Additional Information' block below.
25. Last Name
    Other Household Member #1
26. First Name
27. Relationship to Client
    -- Select One --SpouseMotherFatherDaughterSonSisterBrotherStepmotherStepfatherStepsisterStepbrotherStepdaughterStepsonHalf-sisterHalf-brotherGrandparentGrandchildGrandmotherGrandfatherAdopted ChildAdopted ParentAuntUncleNieceNephewCousinRoommateCaregiverNeighborPartnerOther
28. Age
30. Last Name
    Other Household Member #2
31. First Name
32. Relationship to Client
    -- Select One --SpouseMotherFatherDaughterSonSisterBrotherStepmotherStepfatherStepsisterStepbrotherStepdaughterStepsonGrandparentGrandmotherGrandfatherAuntUncleNieceNephewCousinRoommateCaregiverNeighborPartnerOther
33. Age
35. Last Name
    Other Household Member #3
36. First Name
37. Relationship to Client
    -- Select One --SpouseMotherFatherDaughterSonSisterBrotherStepmotherStepfatherStepdaughterStepsonStepsisterStepbrotherHalf-sisterHalf-brotherGrandparentGrandmotherGrandfatherAuntUncleNieceNephewCousinRoommateCaregiverNeighborPartnerOther
38. Age
40. Last Name
    Other Household Member #4
41. First Name
42. Relationship to Client
    -- Select One --SpouseMotherFatherDaughterSonSisterBrotherStepmotherStepfatherStepdaughterStepsonStepsisterStepbrotherHalf-sisterHalf-brotherGrandparentGrandmotherGrandfatherAuntUncleNieceNephewCousinRoommateCaregiverNeighborPartnerOther
43. Age
47. REASONS FOR CONCERN/REFERRAL
    (Check all that apply)
49. ADULT SERVICES

    (Individuals/Families)

    1. Access to Health/Behavioral Health
    2. Application Assistance & Support
    3. Community Resources (Individual/family)
    4. Disability Services & Support
    5. Employment/Volunteer Program (Job prep)
    6. Financial Management (Budget, etc)

    1. Housing Stabilization/Eviction
    2. Opioid Education / Naloxone
    3. Other (provide further info below)
    4. Re-Entry Services (release from jail/prison)
    5. Utility Assistance (gas, electric, etc.)
    6. Veteran Assistance (Resources/Referrals)
51. CHILDREN'S SERVICES

    (Parent/Children)

    1. Access to Health Behavioral Health
    2. Child Growth and Development
    3. Community Resources - Parents/Children
    4. Cribs for Kids
    5. Early Childhood Development Screenings
    6. Family and Youth Lifeskills
    7. In Home Family Support

    1. In Home Parent Education
    2. Opioid Education / Naloxone
    3. Other (provide further info below)
    4. Parenting Classes
    5. System of Care
    6. WIC - Women, Infants and Children
53. SENIOR SERVICES

    (age 60 or over)

    1. Access to Health/Behavioral Health
    2. Community Resources for Seniors
    3. Health & Wellness Activities
    4. Home-Delivered Meals
    5. Homemaker Services
    6. Non-Emergency Medical Transportation
    7. Opioid Education / Naloxone

    1. Other (provide further info below)
    2. Powerful Tools for Caregivers
    3. Senior Center Meals/Nutrition Education
    4. Senior Center Transportation
    5. Socialization
    6. Volunteer Opportunities
55. ADDITIONAL INFORMATION REGARDING FAMILY SITUATION:
59. REFERRING PARTY INFORMATION
61. Agency Certification

    1. I certify the Family has agreed to receive contact from Lyon County Human Services.
63. Agency Name*
64. Referred by*

    (Point of Contact)

65. Referral Source

    1. Self
    2. Law Enforcement
    3. Community Partner
    4. Internal
67. Agency Phone Number*
68. Agency E-mail
70. Lyon County Human Services will typically respond within 5 business days. If you have a more immediate need, please call (775) 577-5009.
Leave This Blank:


72. 1. Receive an email copy of this form.
73. Email address

    This field is not part of the form submission.

74. Submit Submit and Print

* indicates a required field