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
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.
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)
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
    6. Community Resources for Seniors

    1. Senior Center Meals/Nutrition Education
    2. Volunteer Opportunities
    3. Health & Wellness Activities
    4. Opioid Education / Naloxone
    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
    6. Early Childhood Development Screenings

    1. Community Resources - Parents/Children
    2. Family and Youth Lifeskills
    3. Child Growth and Development
    4. Opioid Education / Naloxone
    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
    6. Re-Entry Services (release from jail/prison)

    1. Community Resources (Individual/family)
    2. Utility Assistance (gas, electric, etc.)
    3. Veteran Assistance (Resources/Referrals)
    4. Opioid Education / Naloxone
    5. Other (provide further info below)
59. ADDITIONAL INFORMATION REGARDING FAMILY SITUATION:*
63. REFERRING AGENCY INFORMATION
65. Date of Referral*
    Date of Referral
66. Agency Name*
67. Referred 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.
82. 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:


84. 1. Receive an email copy of this form.
85. Email address

    This field is not part of the form submission.

86. Submit Submit and Print

* indicates a required field