Counseling Clinic Outreach Request Form

Please fill out the following form for any requests for presentations or tabling events for the counseling clinic.
*Please note that some topics may be better suited for the Health Education Resource Center (HERC) and your outreach request may be forwarded to them.
*Please place requests at least three weeks in advance to ensure availability

Name Name First Last
Department/Organization
Phone Phone - ### - ### ####
Email
Best way you can be reached:
Outreach type

Outreach type Lecture/presentation Panel Tabeling Event Other Other
Target Audience:

Target Audience: Faculty/Staff Students-Class Students-RSO Other Other
Expected number of people:
Pressentation Topic *

Pressentation Topic Counseling Clinic and Mental Health Resources How to Respond in a Mental Health Crisis Stepped Care Model Stress Managment Self-Care Tips on Anxiety Relationships/Boundaries suicide prevention/awareness Other Mental Health Related Topic Other Mental Health Related Topic

May pick more than one. Some topics may be forwarded to the HERC
Date of Presentation Date of Presentation / MM / DD YYYY
Time of presentation Time of presentation : HH MM AM/PM
Expected Length of Time for Presentation
Technology Available

Technology Available Yes No
Additional Comments: