Counseling Center and Prevention Services Outreach Request Form
Thank you for your interest in outreach programming. In order to help us evaluate and support your request, please provide the following information.

Presentations will be covered by staff, clinicians, and/or mental health ambassadors (https://prevention.dasa.ncsu.edu/mental-health-ambassadors/). Please ensure that we have at least 2-3 weeks to confirm coverage with staff/clinicians who also maintain clinical and case management loads.

Email *
Point person for the program (name and email):
Preferred Date/Time
If applicable, please select the topic area you are interested in.
If the program focus/title you are interested in was not in the above list of options, or you would like to provide additional information, please include that here:
Type of Event
Clear selection
If applicable, please provide any specific learning objectives:
Estimated attendance (Please note that we require a 10 person minimum. If you do not expect to meet that minimum, please email us at cou-outreach@ncsu.edu)
Clear selection
Population
College (if applicable)
Clear selection
Please provide any additional population-specific information about the intended audience you would want us to consider
Length of Program:
Clear selection
Program location or Zoom link:
Submit
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