Basic Needs Assistance Form v2

Basic Needs Assistance Form v2

If you are a UC San Diego student who is facing challenges with your access to adequate food, stable housing, or general resources, you're encouraged to complete this form. This form will:
- Provide individual resource suggestions
- Connect you with supportive staff for a Basic Needs Consultation
- Be an opportunity for you to discuss resources and receive advisement as to what may be available to you on and/or off campus.

If you have any questions regarding financial aid, please feel free to contact the Financial Aid and Scholarships Office via email at finaid@ucsd.edu, during their Virtual Counseling / Walk-in Advising hours Mondays, Wednesdays, and Fridays from 8 a.m. to 4:30 p.m. and Tuesdays and Thursdays from 10 a.m. to 4:30 p.m. via Zoom (UCSD.ZOOM.US/MY/FASZOOM1), by phone on Mondays through Fridays from 10 a.m. to 12:30 p.m. at 858-534-4480, or in-person Mondays, Wednesdays and Fridays from 8 a.m. to 4:30 p.m. and Tuesdays and Thursdays from 10 a.m. to 4:30 p.m.

Please note that this reporting form is NOT monitored 24/7. If this is an emergency or you need immediate assistance, please call UCPD at (858) 534-4357 or 9-1-1.

If your housing is impacted within the next 24 hours, please call the Hub Basic Needs Center during Business Hours, M-F 8 a.m. to 4:30 p.m. at 858-246-2632 so that Basic Needs Staff may elevate your case and fill out this form.

Name Name First Last
PID
Must be 8 digits. Currently Entered: 0 digits.
Email
Phone Phone - ### - ### ####
I need support with (select all that apply):

I need support with (select all that apply): Food Resources Housing Resource Options Financial Literacy support Technology support Dependents Support (A student with a dependent(s) is a student that supports one or more other individuals and can be a parent, caregiver, or guardian) General Basic needs Medical Expenses Other Other

If you have selected "Dependent support", please consider filling out the Students with Dependents Assistance form: https://tinyurl.com/SwDAF
Are your current basic needs concerns due to an unforeseen change in your life?

Are your current basic needs concerns due to an unforeseen change in your life? Yes No Other Other
Are your current basic needs concerns an ongoing need?

Are your current basic needs concerns an ongoing need? Yes No Other Other
Please include a brief description of assistance needed:
In order for our staff members to holistically assess your needs, please answer the following questions related to your food, housing, and financial well being.
How is your tuition funded?
Are you currently employed?

Are you currently employed? Yes No
How many hours do you work a week?
Are you currently looking for a job?

Are you currently looking for a job? Yes No Other Other
What other Basic Needs resources have you been connected with?

What other Basic Needs resources have you been connected with? iTable CalFresh Yes! Food Program Triton Pantry Food Recovery Network Food Notification App Hygiene Form None of the above Other Other
Do you live on or off campus?

Do you live on or off campus? On-Campus Off-Campus Other Other
Can you describe your housing situation (if applicable)?

Example: off-campus with relatives but covers majority of rent
How did you find the Basic Needs Assistance Form?

How did you find the Basic Needs Assistance Form? Basic Needs website (basicneeds.ucsd.edu) UC San Diego website (ucsd.edu) Social Media Referral from UC San Diego staff Other Other
In order to best assess your needs during the one-on-one (Zoom) Basic Needs Consultation, we may need to communicate with the Financial Aid & Scholarships Office. Do you give your consent for Financial Aid to release your information to us?

In order to best assess your needs during the one-on-one (Zoom) Basic Needs Consultation, we may need to communicate with the Financial Aid & Scholarships Office. Do you give your consent for Financial Aid to release your information to us? Yes No
I acknowledge that I will be prepared to discuss expenses categorically (rent, food costs, transportation, etc.) during my meeting with a supportive staff member. A budget sheet will be available to use upon submitting this form.

I acknowledge that I will be prepared to discuss expenses categorically (rent, food costs, transportation, etc.) during my meeting with a supportive staff member. A budget sheet will be available to use upon submitting this form. Yes, I will be prepared to discuss my expenses.
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