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Submit a Referral for Resources

Student and Family Outreach Program

Please complete this form if you, your family, or someone else:

  • Needs help applying for health insurance (Health First Colorado (formerly Medicaid) / CHP+)
  • Needs access to community resources (food, clothing, counseling, etc.)
  • Needs Homeless Assistance (please note that under the McKinney-Vento Act, students in any of the following situations may qualify for homeless assistance: students who are living "doubled up" with family or friends due to economic hardship; students who are living in inadequate housing that lacks proper utilities or electricity, windows or walls, or has an insect or rodent infestation; students who are living in homeless shelters; students who are living in parks or cars; students who are completely unsheltered)
  • Is a youth not living with their parent or legal guardian, involuntarily, due to economic hardship or family conflict
  • Is involved with the child welfare system, including foster care and kinship placement

Only one referral needs to be submitted per household.

NOTE: If you are referring someone else, please make sure that they have provided consent prior to completing and submitting this form

Required

RECIPIENT INFORMATION
If You Are an Adams12 Staff Member, Have You Consulted With Members of Your School's Mental Health and Counseling Team and/or Family Outreach Liaison? required
Student Namerequired
First Name
Last Name
Must contain a date in M/D/YYYY format
If the recipient listed above is a student please specify their school.
If the recipient listed above is an Adams 12 student please supply their student ID number (if known
If the recipient listed above is a student in Adams 12 please supply their household ID number
County of Residence
Parent/Guardian NamerequiredIf you are a student not living with your parent or legal guardian, please write None.
First Name
Last Name
If you are a student not living with your parent or legal guardian, please write None.
What is/are the Best Way(s) to Communicate?Please verify that the phone number and email address are correct.
Please verify that the phone number and email address are correct.
What is/are the Best Time(s) to Communicate?

SUBMITTER INFORMATION

Submitter NamerequiredName of the person making referral. If referral made by an AD12 employee, include title & building
First Name
Last Name
Name of the person making referral. If referral made by an AD12 employee, include title & building
Must contain only numbers
If referring someone else, please make sure that they have provided consent. If not, explain below
If you are an Adams 12 student submitting a referral for yourself, is your parent/guardian aware of this referral?
Reason for contactingrequired