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Intake Request Form
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Our staff monitors these requests during business hours only M-F 8am-5pm.
If you're facing an emergency, call 911 immediately. For non-emergency resources, dial 211 to connect with community services.
GWC Resources:
For 24/7 Virtual Therapy for Timely Care for FREE
GWC Mental Health Brochure
GWC Mental Health Resources
Basic Needs Resource Directory
Basic Needs Flyer
At Golden West College we understand that not everyone's path to success is straightforward. Our Student Services team is here to help all students overcome challenges outside of the classroom. Our team will connect you with on-campus and community resources tailored to your needs.
Note: Financial assistance is reviewed on a case-by-case basis.
Who is filling out the form
-- Please Select --
Classified Staff
Faculty
Management
Student
Full Name
Email Address
Student Information
First Name
Last Name
ID
Preferred Language
English
Spanish
Vietnamese
Other
Select the best status that applies to you
I am a credit student
I am a non-credit student
I take credit and non-credit courses
I am enrolled but not registered this semester
Do you have children?
Yes (Under the age of 18)
Yes (Above the age of 18)
Yes (Under and above the age of 18)
No
Assistance Currently Receiving
Do you receive any of the following assistances?
Do you receive any of the following assistances?
CalFresh (Food Stamp)
CalOptima
CalWORKs
Medi-Cal
Medicare Emergency
Medical General
Relief Childcare
Supplemental Security Income
In which of the programs are you currently enrolled? (Select all that applies)
In which of the programs are you currently enrolled? (Select all that applies)
Financial Aid
EOPS (Extended Opportunity Programs and Services)
CalWORKS
The Stand: Basic Needs Center
DSPS (Disabled Students Programs and Services)
Dream Success
Golden Pride
Mesa/Raices
Puente
Academic Success Center
Campus Life (Clubs & Student Government)
Veterans Resource Center
Career Center
Transfer Center
Housing Status
Are you unhoused?
-- Please Select --
Yes
No
Going to be soon
Are you under the age of 24?
Are you under the age of 24?
Yes
No
How long have you been unhoused?
-- Please Select --
Going to be unhoused soon
1-6 months
6 months - 1 year
2+ years
Have you received an eviction notice or pay or quit notice?
Have you received an eviction notice or pay or quit notice?
Yes
No
If you received an eviction or a pay or quit notice, please upload the documentation.
Upload a pdf or word document
Are you facing an unforseen situation or concern?
Are you facing an unforseen situation or concern?
Yes
No
Are you in need of financial assistance?
(An appointment is needed to determine eligibility for each case.)
Are you in need of financial assistance?
(An appointment is needed to determine eligibility for each case.)
Yes
No
Areas of Assistance Needed
Are you interested in an appointment for on campus resources/ community resources?
Are you interested in an appointment for on campus resources/ community resources?
Yes
No
In what areas do you need assistance in?
In what areas do you need assistance in?
Parenting
Housing
Food
Health
Hygene
Clothing
Other
Are you interested in applying for CalFresh (foodstamps)?
Are you interested in applying for CalFresh (foodstamps)?
Yes
No
In the last 12 months, were you ever worried you would run out of food before you had money to buy more?
In the last 12 months, were you ever worried you would run out of food before you had money to buy more?
Often true
Sometimes true
Never true
Don't know/Prefer not to answer
In the last 12 months, did you ever run out of food and not have money to buy more?
In the last 12 months, did you ever run out of food and not have money to buy more?
Often true
Sometimes true
Never true
Don't know/Prefer not to answer
Please explain your situation as best as possible.
Typing your name exactly as it appears below signifies you are completing this form using an electronic signature. I agree with my electronic signature shall have the same effect as my written signature.
Typing your name exactly as it appears below signifies you are completing this form using an electronic signature. I agree with my electronic signature shall have the same effect as my written signature.
Yes
Signature
Submit
