Tech Help United Intake Form * = Required field * = Optional field Contact Information Full Name * Today's Date * Email * Phone Number * Preferred Contact Method * —Please choose an option—EmailPhoneText/SMS Preferred Language * EnglishFrenchKhmerPortugueseSpanishSwahiliOther Zip Code * Demographic Information Your Age * —Please choose an option—under 1818-2425-3435-4445-5455-6465+Prefer not to say Your Gender * —Please choose an option—FemaleMaleNon-BinaryPrefer not to say Your Ethnicity (Check all that apply) * AsianBlack/African AmericanHispanic/LatinoNative American/Alaskan NativePacific IslanderWhite/CaucasianOther What additional ethnicities do you identify with? * Internet Access Do you have access to an internet connected device? * YesNo Please tell us why you currently do not have internet access. (Check all that apply) * Can’t afford internet serviceConcerned about privacy/security onlineDon’t have a device to access the internetDon’t know how to set it upDon’t need or want internet accessNo internet service is available where I liveOther Are you interested in learning about affordable Internet options? * YesNo Device Availability Do you have access to any of the following devices? (Check all that apply) * SmartphoneTabletLaptopDesktopNone of the above What is the condition of the device that you primarily use? * —Please choose an option—NewGoodFairPoor Digital Skills Assessment How would you rate your skill level with digital/electronic devices? * —Please choose an option—BeginnerIntermediateAdvanced Which specific skills do you need help with? (Check all that apply) * Computer BasicsEmail Setup/ManagementInternet Safety/BrowsingOnline BankingSocial MediaTablet/Smartphone BasicsZoom/Video ConferencingAnything else? Specific Questions and Concerns How can United Way of Greater Nashua assist you today? * Goals and Interests What are your main goals for using technology? (Check all that apply) * Accessing Health ServicesJob SearchingManaging FinancesOnline LearningStaying Connected with Family/FriendsOther goals? Are there specific websites, resources, or training that you are interested in? * Additional Information Do you have any disabilities or require special accommodations? * YesNo Please list your disabilities. (One disability per line) * Closing Thoughts Is there anything else you would like us to know? * Δ
