Outreach Request Form
Please provide all information requested below. If you have questions about a request, please contact the Coordinator of Outreach, Dr. Jennica Karpinski, 937-229-3141 or
Title of Event, if applicable
Ally Training (winter and summer breaks)
College Mental Health Issues
Eating Disorders and Concerns/Body Image
General Information about the Counseling Center
Grief and Loss
Helping Someone in Distress
Homesickness/First Year Success
Kiersey Group Interpretation
MBTI Group Interpretation
Type of Service Requested
Graduate Students (who are not graduate assistants)
Number of People Expected
We request a minimum of ten audience members
Preferred Date of Event
Please indicate the ideal date for your program. Requests received at least ONE MONTH in advance with at least THREE possible dates have a greater likelihood of being accommodated. Outreach Programming is generally scheduled Monday through Friday. We are able to accommodate events outside of this time on a case-by-case basis. Requests can be made up to one year in advance. Please type "flexible" in the box below if you do not have a specific date in mind.
Preferred Time of Event
Please indicate the ideal time for your event. Please type "flexible" in the box below if you do not have a specific time in mind.
Alternate Dates and Times
Please indicate alternative dates and times for your event, if applicable.
Where will the event be located?
Please indicate where you would like the event held. If you do not have a location yet, please type "flexible" in the box below. Please ensure that the location is reserved for the date and time decided on for your event.
Please indicate what will be available for our presenters to use.
Computer with USB port
Dry Erase board and markers
Seating that can be arranged to accomodate presenter needs
Other Pertinent Information
Please provide us with any additional information or requests about your event.
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