Student Referral Form for Housing and Basic Needs Support

This form is to help identify students experiencing homelessness, housing insecurity, or basic needs insecurity, so that they may receive appropriate support through the Counseling and Wellness Center’s GSU4U program and HOUSE Task Force.

1. Faculty Member Information

Name:
Department:
Email:
Phone Number (optional):

2. Student Information

Student's Name:
Student's ID (if available):
Student's Email:
Student's Phone:
Preferred Contact Method (Email or Phone):
Preferred Pronouns (optional):

3. Reason for Referral

Select all that apply:

Homelessness
(e.g., living in shelters, cars, couch-surfing, etc.)
Housing insecurity
(e.g., risk of eviction, unstable housing situation)
Food insecurity
(e.g., lacking consistent access to adequate food)
Financial insecurity impacting basic needs
(e.g., inability to meet essential expenses)
Other (please specify)

4. Observations and Concerns

Please provide any relevant observations or concerns regarding the student’s situation (if known). This may include attendance issues, signs of distress, or other indicators:

5. Student’s Awareness of Referral

Is the student aware of this referral?

6. Additional Information (optional)

Any other details that might be helpful for connecting the student to appropriate resources: