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Nevada 211, a program of the Nevada Department of Health and Human Services, is committed to helping Nevadans connect with the services they need.

SERVICES TO AGING & DISABILITY

Nevada Request for Assistance

Complete this form and tell us what you need. We will get you connected to a local provider, volunteer, government agency to meet your needs.

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1 Step 1
Do you currently receive support from any aging services organization?Required
If so, which organization?
Tell us what you need:Required - select all that apply
If yes which services.full name
If other please specify.
Do you currently have a primary care provider?Required
If yes please provide their name.full name

Tell us how to contact you:

First NameRequired
Last NameRequired
Age
Telephone NumberRequired
Zip CodeRequired
Email Address
Please select your language
Are you completing this form for someone else?Required
Since you are completing this form on behalf of another individual, please make sure their information is provided in the fields above and enter your information in the “Caller” fields below.
Caller First NameRequired
Caller Last NameRequired
Caller Phone NumberRequired
Is the individual aware that you are completing this form on their behalf?Required
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