* indicates a required field

2. Individual being referred (complete all known information)
4. First Name
5. Last Name
6. Date of Birth
8. Address1
10. Address2
12. City
13. State
14. Zip
16. Phone Number
17. Email Address
19. Please Check which housing situation best describes the household

    1. Homeless
    2. Shelter
    3. Rent Home
    4. Own Home
    5. Lives with Family/Friends
    6. Hospital
    7. Assisted Living
    8. Incarcerated
    9. Motel/Hotel
    10. Unknown
    11. Other
23. Household Member Information
25. 1. Household Member Name

    First & Last Name

    
    

26. 1. Relationship to Client
    -- Select One --SpouseParentChildSiblingGrandparentGuardian CaregiverRoommateOther
27. Approximate Age
31. 2. Household Member Name

    First & Last Name

    
    

32. 2. Relationship to Client
    -- Select One --SpouseParentChildSibling GrandparentGuardianCaregiverRoommateOther
33. Approximate Age
37. 3. Household Member Name

    First & Last Name

38. 3. Relationship to Client
    -- Select One --SpouseParentChildSiblingGrandparentGuardianCaregiverRoommateOther
39. Approximate Age
43. 4. Household Member Name

    First & Last Name

44. 4. Relationship to Client
    -- Select One --SpouseParent ChildSiblingGrandparent GuardianCaregiverRoommate Other
45. Approximate Age
49. If you need to add additional household members, please include them in the text box provided below.
51. Additional Household Member Information
55. Please provide a brief explanation of the most immediate needs for the household. *If requesting cremation assistance please provide the descendants' name and age in this field.*

    Please do not include social security numbers or protected information. 

59. 
    

    Storey County Health and Community Services will typically respond within 5 business days. If you have a more immediate need, please call (775) 847-0957.

63. Agency Name (If Applicable)

    Please provided the name of the agency making the referral. 

64. Name of Individual Providing Referral

    Please provide the name of the person within the agency making the referral. 

66. Reporting Individual's Phone Number
67. Reporting Individual's Email Address
Leave This Blank:


68. 1. Receive an email copy of this form.
69. Email address

    This field is not part of the form submission.

70. Submit