1155 E 9th St. Reno, NV 89512
(775) 328-2575 or Fax (775) 325-8025
Services Being Requested
Is Client Aware and Receptive to Referral/Services?
Referral Name (person needing assistance)
Current Date
Address
Date of Birth
SSN Known?
Gender
Lives Alone
Spouse Full Name
Spouse Date of Birth
Support Details Known?
Support Name
Name of Individual Making the Referral
*Washoe County Notice of Privacy Practice is available for review on the Washoe County Seniors Services Webpage under the Form section or click the below link.
Washoe County Senior Services Forms
