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such as adequate food, stable housing, or general technological resources, you’re encouraged to complete this form.  \nThis 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  \nFirst Name:*  \nLast Name:*  \n10 Digit Student ID \\#,(CSID):*  \nPhone (skip if no phone):  \nEmail:*  \nConfirm Email:*  \nPreferred method of contact* (Select all that apply)  \n☐ Phone ☐ Email  \nHow did you hear about this San Diego City College Basic Needs Assessment?* (Select the most applicable)  \n☐ City College Website (ex. banner notification, student affairs page, etc.)  \n☐ E-mail communication  \n☐ Social media post (Facebook, Instagram, Twitter, etc.)  \n☐ Class announcement (Canvas notification, faculty email, etc.)  \n☐ Other: If “Other,” please specify  \n_______________________  \n_______________________  \nBasic Needs Intake Assessment Sample | John Burton Advocates for Youth P. 1  \n\n|  |  |  |\n| --- | --- | --- |\n\nAre you currently enrolled at San Diego City College?*  \n☐ Yes ☐ No  \nPreviously enrolled?  \n☐ Yes ☐ No  \nNumber of Units Enrolled?*  \n☐ Part-Time ☐ Full-Time  \n(less than 12 units) (12 or more units)  \n☐ Unsure  \n☐ Unsure  \nHave you completed your FAFSA for the current academic year?*  \n☐ Yes ☐ No  \nAre you currently working?  \n☐ Yes ☐ No  \nAre you receiving any of the following forms of aid or income?  \n(Check all that apply)*  \n☐ California Promise Grant  \n(Formerly BOGW)  \n☐ CalFresh  \n(SNAP, EBT, food stamps, WIC)  \n☐ CalWORKs  \n(Cash aid/TANF)  \n☐ CARES Act Funding  \n☐ Financial Aid  \n(ex. Pell Grant, Cal Grant, and/or Loans)  \n☐ General Relief  \n☐ Other: If you select “Other” please specify.  \n_______________________  \n_______________________  \nAge*:  \nGender*:  \n☐ Male  \n☐ Female  \n☐ Non-Binary  \n☐ Decline to State  \n☐ Other: If you select “Other”please specify.  \nMarital Status*  \n(Select most applicable)  \n☐ Single/Never married  \n☐ Married/Domestic partnership  \n☐ Divorced ☐ Widowed ☐ Separated  \n☐ Decline to state  \nBasic Needs Intake Assessment Sample | John Burton Advocates for Youth P. 2  \n\n|  |  |  |\n| --- | --- | --- |\n\nEthnicity  \n☐ American Indian/Alaska Native  \n☐ Asian  \n☐ Black/African American  \n☐ Filipino/a  \n☐ Latinx  \n☐ Pacific Islander  \n☐ White ☐ Two or More Races ☐ Unknown  \n☐ Decline to state  \nPrimary Language  \n☐ English ☐ Spanish ☐ Other: If you select “Other”please specify  \nAre you accessing any of the following services at San Diego City College?* (Check all that apply)  \n☐ CalWORKs  \n☐ Cooperative Agencies Resources for Education (CARE)  \n☐ disAbility Support Programs and Services (DSPS)  \n☐ Extended Opportunity Programs & Services (EOPS)  \n☐ Food Pantry  \n☐ Monarch School Project  \n☐ San Diego Promise Program ☐ Student Health Center/Mental  \nHealth Counseling Center  \n☐ None/Not applicable  \n☐ Other: If you select “Other” please specify.  \n_______________________  \n_______________________  \nCity College has other resources available to help. Please check the boxes below if you need resources or assistance in other areas:  \n(Check all that apply)  \n☐ Health Insurance (ex. Covered California, Med-Cal)  \n☐ Technology resource (Chromebook loaner program)  \n☐ Other: If you select “Other” please specify.  \n___________________________________________________  \nBasic Needs Intake Assessment Sample | John Burton Advocates for Youth P. 3  \n\n|  |  |  |\n| --- | --- | --- |\n\nPLEASE ANSWER THE FOLLOWING QUESTION ON A SCALE FROM 1 TO 10 (10 BEING VERY CONFIDENT, 1 BEING IN CRISIS)  \nHow confident are you that you will have secure housing this semester?*  \n1 2 3 4 5 6 7 8 9 10  \nHow confident are you that you will have consistent access to food this semester?*  \n1 2 ","cbCaidoUeQHUFzpX","https://ap.wps.com/l/cbCaidoUeQHUFzpX","pdf",99709,"English","# BASIC NEEDS INTAKE ASSESSMENT SAMPLE\n## Student contact and background\n## Enrollment, FAFSA, work, and aid/income\n## Demographics and primary language\n## Service access and additional needs\n## Housing and food confidence scale\n## Living situation details\n# HOME CITY NON-EMERGENT FINANCIAL ASSISTANCE","[{\"question\":\"Who should complete the Basic Needs Intake Assessment form?\",\"answer\":\"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.\"},{\"question\":\"What information does the form collect about a student’s needs?\",\"answer\":\"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.\"},{\"question\":\"How are housing and food needs assessed in the form?\",\"answer\":\"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.\"}]","Basic Needs Intake Assessment Sample - San Diego City College | PDF",1789239244]