Outreach Request Form

The Counseling Services Outreach Team is dedicated to educating students and to providing information regarding a wide variety of issues. If you would like to have someone from the Department come to your place (residence hall, community, class, etc.) to give a presentation, facilitate a discussion table or provide health education materials, please complete the form provided below. Completing the form completely will expedite the process. FOR PREPARATION AND PLANNING, YOUR REQUEST MUST BE SUBMITTED TO US AT LEAST 2 WEEKS BEFORE THE REQUESTED DATE OF THE EVENT.

Fields marked with an asterisk (*) are mandatory

*Person making request:
Position:
Organization or Department:
*Telephone (Please include area code):
*E-mail:
Current Mailing Address (Please include Street, City, State, and Zip):
*Topics:
Comments/Special Instructions:

Presentation day and time
1st choice:
2nd choice:
Time of Event:
Need confirmation date by:
Size of audience:
Gender of group:
Age of group:
Length of program (in minutes):
Location of Presentation:

Do they have equipment we can use during the presentation?
VCR:
 Yes
No
Monitor:
 Yes
No
Other:

Please call the Counseling Center (extension 5157 or 609-896-5157) to confirm receipt of your request.

When you are satisfied, please click