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: *

Are you currently facing any academic or personal challenges?*

Where could you most use support?*:

How can the support center best assist you with your current challenges?*

Please list any accommodation you may need.

Do you need any adaptive technology? If yes, please list below.

Please check your preferred method(s) of communication (check all that apply)*

Please check the time of day you prefer for communication*