Outreach Request

In order to best accommodate requests, please submit inquiries at least 2-3 weeks in advance.

Program/Event Information
Event/Program Topic*

What is the purpose of the outreach event?
Intended Goals or Outcomes of the Program/Event:*

What do you hope to accomplish with this outreach activity? What can University Counseling Services/Health Promotion and Wellness provide? (Examples: education/information, discussion/consultation, clinical support during/after an event, etc)
Audience:*

Who will be attending the event/activity?
Expected number of students attendees:*
Expected number of other attendees:
Length of Program/Event

How long is scheduled for the outreach actvitiy?
Location

Where will the outreach activity take place?
Preferred Date and Time*

Please include up to 3 available times/dates.
Event/Program Format:*
What format are you hoping for? (presentation, facilitated conversation, etc) What resources are available or needed? (AV setup, white board, etc)
Additional Information:
What additional information do you want us to consider as we process your request?
Event/Program Contact
Name*
Email:*
Phone Number:

Program/Event Information