2025-2026 Homeless/At Risk Intake Form
Contact Information
Student First Name
Student Last Name
Preferred Email
Date of Birth
Home or Cellphone
Please indicate the type of homelessness you are experiencing.
I have worked with a shelter or high school.
I have not worked with a shelter or high school.
Agency Information
Name of Agency
Contact Person
Email Address of Agency
Interview Request
Please describe the nature of your homelessness/at risk of homelessness. We do not need to know why you are homeless or at risk, we just need to know your current living situation.
What is the best way to meet with you?
Phone
In-Person
Virtual
No Preference
What is the best time and date to meet with you?
Once you submit this form either Casey Lehmann, our Financial Aid Manager, or Liz Nameth, our Financial Aid Systems Analyst will set up an appointment with you to discuss your situation.
WARNING: If you purposely give false or misleading information on this worksheet, you may be fined, be sentenced to jail, or both.
Contact Information