Referral for Resources Form

If this concern requires immediate attention, please contact Campus Police at (618) 985-2828, extension 8218. They are available 24/7 to provide assistance in urgent or emergency situations.

Please use this form to report needs you have observed or students have reported to you. Submitting this form will allow staff to reach out to the student to provide guidance and access to internal or external resources.

Reporting Party

• JALC Employee
• Non-Employee Third Party
• JALC Student

Reporting Party Information

Name *

First

Last

Department/Title *

Email *

Email

Confirm Email

Phone *

Student Information

Student Name *

First

Last

Student ID (optional):

Needs Being Reported

It is my observation that the above listed student is in need of support in the following areas (Check all that apply): *

• Addiction
• Clothing
• Course Materials/Textbooks
• Disability Support Services (for students who self-disclose a documented disability)
• Employment
• Families
• Food Insecurity
• Housing Insecurity
• Legal Assistance
• Mental Health Needs
• Physical Health Needs
• Transportation
• TRIO Program
• Tutoring
• Utilities
• Other

Families *

• Childcare
• Diapers or other supplies

Food Insecurity *

• Lacking regular access to food
• Food insecurity affecting children
• Limited food supply

Needs the in

Housing Insecurity *

• Experiencing homelessness
• Unstable or at-risk housing situation
• Facing potential housing displacement

Transportation *

• Vehicle maintenance or reliability issues
• Limited access to fuel
• Risk of withdrawal due to transportation barriers

Other (please provide a brief description): *

Please provide any additional information about the student needs (optional):

Submit