Resources and Homeless Referral

Please complete this form if your family or a family that you are referring:

* 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; and students who are not living with their parent or legal guardian, involuntarily, due to economic hardship or family conflict)

Please be aware that due to a large number of referrals in recent weeks, it may take up to five to seven business days for a Community Resource Specialist to address your referral. If you are an Adams 12 staff member, you can find resources in the Desktop Reference for Staff. Please contact Lisle Reed if you need access to the Desktop Reference.

Recipient Information

Student First Name *

Student Last Name *

Student Date of Birth *

Month

Day

Year

School

If the recipient listed above is a student please specify their school.

Student ID#

If the recipient listed above is a student please supply their student ID number.

County of Residence *

Phone

Parent / Guardian Name

If the recipient listed above is a minor please supply the name of their parent or guardian.

Household Language

Submitter Information

Submitter Name & Job Title *

Name of the person making this referral. If the referral is made by an Adams 12 employee, please include job title and school/building.

Submitter E-mail *

Submitter Phone

If You Are an Adams 12 Staff Member

What Resources Have You Already Provided to the Family Using Either the Desktop Reference or the Shared Google Drive?

If You Are an Adams12 Staff Member

Yes

Please Click "Yes" to Affirm that You Have Consulted With Members of Your School's Mental Health and Counseling Team Prior to Submitting This Referral

Best Time and Method to Reach Family

When Was the Family Notified That You Would be Making this Referral?

Consent should always be given by the family prior to making a referral to SFOP. Please contact Lisle Reed if you have questions.

Reason for Contacting *

Health Insurance

Homeless Assistance

Community Resource

Comments: Please provide as much detail as possible. *

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Resources and Homeless Referral