Employee Self-Referral Form for Basic Needs | Governors State University

Personal Information

Name:
Department:
Employee ID:
GovState Email:
Cell Phone:

Support Needed

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 need financially
(e.g., struggling to cover essential expenses)
Other
(please specify)

How Can We Help

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

Availability

Please provide the best days times and method to contact you: