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