Student Support Intake Form.

Thank you for reaching out. Durham Tech is committed to supporting our students in accessing the resources you need to stay well and be successful. Submit this intake form to share about the resources you or your family may need at this moment, and we will do our best to connect you with appropriate supports on campus and in the community.

After you submit this form, a member of our student support team will be following up by phone or email as soon as possible.

For immediate support in a crisis, please visit Durham Tech's Counseling Services page for information about getting help right away.

Date:  10/27/2021

First Name:  
Last Name:  

Name you go by (if different from above):  

Durham Tech ID:  
         Don’t Have or Know participant ID Number
Please use your 7-digit Durham Tech Student ID number

Phone: 

Email: 

Are you the parent/guardian to any biological, adopted, step, or foster children who live in your household? 

Do you have safe, stable housing? 

What type of resources are you looking for assistance in connecting with? 
Food
Housing
Employment
Financial assistance for rent, utilities, etc.
Financial assistance for tuition or school-related expenses
Computer or internet access
Transportation
Healthcare
Mental health or counseling services
Child care
Support for anxiety and stress during COVID-19
COVID-19 vaccination information
Other:
None of the Above

If you feel comfortable, please share more about your current challenges and hopes.