University Counseling Center - Outreach/Consultation Request Form
To submit an Outreach Request, please complete the form below. The Outreach Coordinator will contact you within two business days to confirm receipt of your request and to ask any further questions, if needed. You will then be contacted when a member of the UCC has been identified to conduct your requested program. (We ask that you make your request at least two weeks prior to your scheduled event. Please note that the UCC cannot guarantee the availability of a counselor for your program.)
Requested Service/Topic
Your answer
Contact Person
Name
Your answer
Position
Your answer
Phone Number
Your answer
Email
Your answer
Program Details
Requested Dates (best days and times)
Your answer
Service Recipient (university organization, residence hall, student group or department)
Your answer
Anticipated Number Attending
Your answer
Service Considerations (needs assessment, preliminary consultation, space needs, equipment, group composition, cautions)
Your answer
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