Counseling Center Outreach Request Form
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Please Fill In The Form Below
Today's Date:
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Requested by:
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E-Mail
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Telephone Number
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Status
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--Please Select--
Student
Faculty
Staff
If Faculty/Staff, Please List Your Department/Division
Please identify audience & estimate number of participants (minimum audience of 10 required)
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Special Accommodations Needed:
Requested Topic of Presentation
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--Please Select--
Addictions (Food, Sex, Gambling)
Adjustment To College
Alcohol/Drug
Anger Management
Anxiety (General, Test, Performance, Speech)
Assertiveness
Body Image/Eating Disorders
Communications Skills
Conflict Resolution
Counseling Center Services
Critical Incident Debriefing
Decision Making
Depression
Diversity (Gender, Racial or Other)
Grief And Loss
Listening Skills
Organizational Skills
Problem Solving
Relationships
Self-Esteem
Sexual Assault
Stress Prevention
Suicide Risk Reduction
Time Management/Procrastination
Other (Please Specify Below)
If Other Topic, Please Specify:
Preferred Date (Contact Us At Least Two Weeks In Advance)
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Preferred Time of Day
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Preferred Length of Presentation
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--Please Select--
30 minutes
45 minutes
1 hour
1.5 hours
2 hours
If Other, Please Specify:
Location (Building & Room)
Is Audio/Visual equipment available in the room? (eg. Smart Classroom)
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Yes
No
If Audio/Visual equipment is required, who will pay the fee?
Upon receipt of this request, a Counseling Center representative will contact you to discuss the details of your request. Thank you!