Basic Needs Intake Assessment Sample - San Diego City College

Sep 12, 2026

Basic Needs Intake Assessment Sample for San Diego City College to support current students facing challenges accessing essential resources such as adequate food, stable housing, or technology. The form collects student contact and identity details, enrollment status, work and FAFSA completion, and income or aid sources including CalFresh, CalWORKs, CARES Act Funding, and financial aid. It also gathers demographic information, primary language, service access at the college, additional resource needs, and confidence ratings about secure housing and consistent food access, along with details of living situation stability.

LanguageEnglish

CategoryForms

FormatPDF

Pages6

Reading Time2 min

AccessFree to download

BASIC NEEDS INTAKE ASSESSMENT SAMPLE

Student contact and background

Enrollment, FAFSA, work, and aid/income

Demographics and primary language

Service access and additional needs

Housing and food confidence scale

Living situation details

HOME CITY NON-EMERGENT FINANCIAL ASSISTANCE

| | | | | --- | --- | --- | BASIC NEEDS INTAKE ASSESSMENT SAMPLE SAN DIEGO CITY COLLEGE BASIC NEEDS ASSESSMENT If you are a current San Diego City College student who is facing challenges with your access to basic needs such as adequate food, stable housing, or general technological resources, you’re encouraged to complete this form. This form will be used to connect you with resources related to your identified areas of need. If you need assistance completing the form or have questions, please contact: XXX-XXX-XXXX First Name:* Last Name:* 10 Digit Student ID \#,(CSID):* Phone (skip if no phone): Email:* Confirm Email:* Preferred method of contact* (Select all that apply) ☐ Phone ☐ Email How did you hear about this San Diego City College Basic Needs Assessment?* (Select the most applicable) ☐ City College Website (ex. banner notification, student affairs page, etc.) ☐ E-mail communication ☐ Social media post (Facebook, Instagram, Twitter, etc.) ☐ Class announcement (Canvas notification, faculty email, etc.) ☐ Other: If “Other,” please specify _______________________ _______________________ Basic Needs Intake Assessment Sample | John Burton Advocates for Youth P. 1 | | | | | --- | --- | --- | Are you currently enrolled at San Diego City College?* ☐ Yes ☐ No Previously enrolled? ☐ Yes ☐ No Number of Units Enrolled?* ☐ Part-Time ☐ Full-Time (less than 12 units) (12 or more units) ☐ Unsure ☐ Unsure Have you completed your FAFSA for the current academic year?* ☐ Yes ☐ No Are you currently working? ☐ Yes ☐ No Are you receiving any of the following forms of aid or income? (Check all that apply)* ☐ California Promise Grant (Formerly BOGW) ☐ CalFresh (SNAP, EBT, food stamps, WIC) ☐ CalWORKs (Cash aid/TANF) ☐ CARES Act Funding ☐ Financial Aid (ex. Pell Grant, Cal Grant, and/or Loans) ☐ General Relief ☐ Other: If you select “Other” please specify. _______________________ _______________________ Age*: Gender*: ☐ Male ☐ Female ☐ Non-Binary ☐ Decline to State ☐ Other: If you select “Other”please specify. Marital Status* (Select most applicable) ☐ Single/Never married ☐ Married/Domestic partnership ☐ Divorced ☐ Widowed ☐ Separated ☐ Decline to state Basic Needs Intake Assessment Sample | John Burton Advocates for Youth P. 2 | | | | | --- | --- | --- | Ethnicity ☐ American Indian/Alaska Native ☐ Asian ☐ Black/African American ☐ Filipino/a ☐ Latinx ☐ Pacific Islander ☐ White ☐ Two or More Races ☐ Unknown ☐ Decline to state Primary Language ☐ English ☐ Spanish ☐ Other: If you select “Other”please specify Are you accessing any of the following services at San Diego City College?* (Check all that apply) ☐ CalWORKs ☐ Cooperative Agencies Resources for Education (CARE) ☐ disAbility Support Programs and Services (DSPS) ☐ Extended Opportunity Programs & Services (EOPS) ☐ Food Pantry ☐ Monarch School Project ☐ San Diego Promise Program ☐ Student Health Center/Mental Health Counseling Center ☐ None/Not applicable ☐ Other: If you select “Other” please specify. _______________________ _______________________ City College has other resources available to help. Please check the boxes below if you need resources or assistance in other areas: (Check all that apply) ☐ Health Insurance (ex. Covered California, Med-Cal) ☐ Technology resource (Chromebook loaner program) ☐ Other: If you select “Other” please specify. ___________________________________________________ Basic Needs Intake Assessment Sample | John Burton Advocates for Youth P. 3 | | | | | --- | --- | --- | PLEASE ANSWER THE FOLLOWING QUESTION ON A SCALE FROM 1 TO 10 (10 BEING VERY CONFIDENT, 1 BEING IN CRISIS) How confident are you that you will have secure housing this semester?* 1 2 3 4 5 6 7 8 9 10 How confident are you that you will have consistent access to food this semester?* 1 2

FAQs

Who should complete the Basic Needs Intake Assessment form?

Current San Diego City College students facing difficulties accessing basic needs such as food, stable housing, or general technological resources are encouraged to complete the form.

What information does the form collect about a student’s needs?

It collects contact details, student ID, enrollment and FAFSA status, whether the student is working, types of aid or income received, demographic data, and which support services the student is accessing at the college.

How are housing and food needs assessed in the form?

Students answer confidence questions on a 1–10 scale about secure housing and consistent food access for the semester, then describe current living situation and housing stability options.

Sep 12, 2026

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