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Counseling Center Outreach Request Form
Please fill out the following request form at least 2 weeks prior to the anticipated date of your program or event.
* Indicates required question
Email
*
Record my email address with my response
Name (First and Last)
*
Your answer
What is your department or student organization?
*
Your answer
Email
*
Your answer
Phone Number
*
Your answer
Preferred date of your request (if date is flexible, please list all options below)
*
Your answer
Preferred time of your request (if time is flexible, please list all options below)
*
Your answer
Location of your request
*
Online
In-person
Flexible for online or in-person
If your request is in-person, please provide the location (if not, please type N/A)
*
Your answer
What type of outreach are you requesting?
*
FYS
Tabling
Talk or presentation on a specific topic
Training
Interview (for academic assignment, media) * Please share your interview questions below
Other:
Who will the audience be for this outreach request?
*
Undergraduate Students
Graduate Students
Faculty
Staff
Other:
How many people are expected to attend?
*
Your answer
Please describe your request (if the request is for an interview, please also list the questions here)
*
Your answer
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