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. Leave This Blank:

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