Self-Referral Form
Student Name
*
First Name
Last Name
Age
Student E-mail
Mobile Number
-
Area Code
Phone Number
Please choose one of the following public colleges you are currently engaged and/or enrolled in Santa Clara County
Please Select
West Valley College
Mission College
Foothill College
Gavilan College
De Anza College
San Jose City College
Evergreen College
San Jose State University
Current Housing Need
Our definition of homelessness includes youth up to the age 25 who lack a fixed, regular, and adequate nighttime residence. This definition includes children and youth who are: sharing the housing of others due to loss of housing, economic hardship, or similar reason; living in shelters, transitional housing, or cares; and staying in motels or campgrounds due to lack of adequate alternative accommodations. You do not need to be living on the street to be considered unhoused or homeless. Please check all that apply to living situation over past 90 days:
Living in a tent
Couch surfing without long-term plan
Sleeping in car, bus, or RV
Living in place not meant for housing (abandoned building, laundry room, etc.)
Moved 3 times within last 90 days
Sleeping in library overnight
Number of people in your household needing housing
Preferred method of contact
Phone call
Email
Submit
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