Resources and Homeless Referral

Community Resources Referral

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

Student & Family Outreach
Recipient Information
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 (if known). You can find this on the student’s IC Summary page.
If you are a student not living with your parent or legal guardian, please write None.
Please verify that the phone number and email address are correct.
Submitter Information
Name of the person making this referral. If the referral is made by an Adams 12 employee, please include job title and school/building.
If you are referring someone else, please make sure that they have provided consent. If that is not possible, explain why in the next section.