Outreach Request Form

Please Note:

To ensure our availability, we suggest that requests for presentations be made a minimum of two weeks in advance of the anticipated program date. Submitted requests will be reviewed by the Counseling Center staff; efforts will then be made to respond to your request in a timely manner.

Please don't fill out this input box.

Today's Date*

First Name*

Last Name*

Email*

Phone*Format (xxx) xxx-xxxx

Department or Organization*

Best Time to be Reached*

Title of Your Event*

How can Student Counseling serve you during this event? (Please select one)*See toolkit menu for more information

Please describe your event.*Please be specific as possible in describing your event

Estimated Number of Participants*

Description of Participants*Major, Age Range, Interests, etc.

Location of Event*

Additional Comments, Requests, or Questions*

Potential Dates and Times*Please list any alternative times and dates in case we are not available on your preferred date.

Enter potential times for the event.