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.

1. Personal Information

Name:
Student ID:
Email:
Phone:
Preferred Contact Method (Email or Phone):
Preferred Pronouns (optional):

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)

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

Best Days and Times to Contact You: