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NYAP Nevada Behavioral Health Services
Referral Form
Referral Source Contact Name
*
First Name
Last Name
Referral Agency
Doctor's office, county department, etc.
Referral's Contact Email
*
example@example.com
Are you referring for yourself or on behalf of someone else?
*
Myself
My Child/Youth
Other
Name of person seeking services
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
If you are referring on behalf of a youth, what is their Parent or Caregiver's name and relation?
First Name
Last Name
Relationship
Your email or the Caregiver's email
*
example@example.com
Your phone number or Caregiver's phone number
*
-
Area Code
Phone Number
Address of person seeking services
Street Address
Street Address 2
City
State
Zip Code
What is the person's County of Residence?
*
Clark County
At this time we are only able to serve these counties. If your county is NOT listed, please call 211 or contact your local child services office for additional assistance.
What concerns are you hoping to address with NYAP Behavioral Health services?
*
What type of services you are interested in?
Diagnostic Assessment
Individual Therapy
Family Therapy
Group Therapy
Community Support
Individual Behavioral Assistance
Psychiatric Services
Medication Evaluations/Management/Behavioral Assistance
Trauma-Focused Cognitive Behavioral Treatment
Educational/Vocational Support
Other
How did you hear about NYAP?
*
Social Media
Google Search
Website
Participant of Other NYAP Program(s)
Friend Referral
Other
Please verify that you are human
*
Click Submit Below to Complete
Once completed, your referral will be processed by the NYAP office nearest you. Most referrals will be processed and contacted within 2 BUSINESS DAYS.
Submit
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