Counseling Center

Outreach Request Form

If you have not received a response after 7 days from the date your request was submitted, please contact Leslie Gerard, Coordinator of Outreach, at 568-6552 or You may also contact Leslie if you have additional questions/requests.

Fields designated with an asterisk are required. Submissions with blank required fields will not properly transmit to the Counseling Center.

Please complete one form for each program topic requested. Please make all requests for programs at least two weeks in advance of the date of the program. The latest a program will be conducted is from 8-9 pm.

Contact Information

Today's Date (mm/dd/yy)
Name * *
Phone Number * *
Email Address * *
Class/Organization Requesting Program
Are you a resident advisor? Yes No
Should the need arise, what's the easiest way for us to contact you?
If by phone, what's the best day of the week and time to contact you?

Program Information

Brief Description of Program Topic:

Reason for Requesting Program: (i.e., low GPAs, recent conflicts, problems with time management)

What are your goals for the intended audience? What do you hope the participants will gain from the CSDC's involvement?

Length of Program (hrs)
Location (Building and Room)

Can the layout of the room identified above be changed to fit the program?

Yes No Unknown

Expected Attendance

Requested Dates/Times (For example: Friday, June 5th from 3pm to 4pm). List a maximum of three choices, with the first choice being most preferred.

Has a program previously been conducted on this topic? Yes No
If "yes," what was the date of the last program?
Is this a Passport Approval program? Yes No

Intended Audience Information

Who will be attending the program? (Check all that apply).


Professional Staff





Graduate Students

Non-College Students


Other (please identify):

Who is the intended audience of the program? (i.e., Sorority members, African Americans, etc.)
What is the primary reason for the audience attending?
Is attendance mandatory? Yes No
How familiar do you expect the average person in the audience to be with the topic?

Not Familiar Somewhat Familiar Very Familiar

To which approach do you think your intended audience will best respond? Please rank the following approaches according to how you think your intended audience will respond (1 being "best response" to 3 "least response").

Video and Discussion
1 2 3
1 2 3
1 2 3
Open Discussion
1 2 3
Other (please explain below): 1 2 3


How motivated do you expect the average person in the audience will be to participate in the program?

Low Medium High

Marketing Information
Have you formally or informally surveyed your intended audience for their level of interest in the program?

Yes No

Will the program be co-sponsored by other organizations?

Yes No

If 'Yes,' please identify:

How will the program be advertised? (Check all that apply):
  1. Flyer
  2. "Word of Mouth"
  3. Email
  4. Other (please explain):
Do you want to be involved in the planning and implementation of the program?

Yes No

If 'Yes,' in what way would you like to be involved?

Additional Information

Please provide us with any additional information that you think will be helpful in responding to your request:

Submit and Clear Form

After pressing the Submit button below your information will be sent to the Coordinator of Outreach in the form of an email. Once your email has been opened you will receive an email confirming that your email has been received and is being reviewed. A member of the Counseling Center will contact you within 1 week of your submitting the request.