Student Support Intake Form

Name :

Your Pronouns:

Phone Number*

Email*

NYU ID (e.g. N12345678):

Program Name:*

Academic Information*:

What courses are you currently enrolled in? Please list by name and/or course numbers: *

<br />

<label for="description">Are you currently facing any academic or personal challenges?*
<br />
</label><textarea name="description" /><br />

Where could you most use support?*:
<br />
<textarea id="00N7i00000Mvmt1" name="00N7i00000Mvmt1" rows="3" /><br />

How can the support center best assist you with your current challenges?*
<br />
<textarea id="00N7i00000Mvmt0" name="00N7i00000Mvmt0" rows="3" /><br />

Please list any accommodation you may need.
<br />
<textarea id="00N7i00000Mvmso" name="00N7i00000Mvmso" rows="3" /><br />

Do you need any adaptive technology? If yes, please list below.
<br />
<textarea id="00N7i00000Mvmsp" name="00N7i00000Mvmsp" rows="3" /><br />

Please check your preferred method(s) of communication (check all that apply)*<br />
<select id="00N7i00000Mvmsw" multiple="multiple" name="00N7i00000Mvmsw" title="Preferred Communication">
<option value="Email">Email</option>
<option value="Phone">Phone</option>
<option value="Text">Text</option>
<option value="Virtual">Virtual</option>
</select><br />

Please check the time of day you prefer for communication*
<br />
<select id="00N7i00000Mvmt2" multiple="multiple" name="00N7i00000Mvmt2" title="Time of Day Preferred Communication">
<option value="Morning">Morning</option>
<option value="Afternoon">Afternoon</option>
<option value="Evening">Evening</option>
</select><br />

</form>

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