Student Self-Referral Form for Housing and Basic Needs Support

If you are experiencing challenges with housing, food, or meeting basic needs, this form will help us connect you with resources and support.

First

Last

Student ID

Phone

Preferred Contact Method (Email or Phone)

Preferred Pronouns (optional)

Support Areas Needed (Please check all that apply)

I am experiencing homelessness (e.g., living in shelters, cars, or couch-surfing)

I am worried about my current housing situation (e.g., at risk of eviction or living in unstable housing)

I need assistance with getting enough food (e.g., lacking consistent access to meals)

I am struggling to meet basic needs financially (e.g., struggling to cover essential expenses)

Other

Please specify other support areas needed

Please briefly describe your situation and any specific help you may need

Best days and times to contact you