CAPS: Outreach and Education

Outreach & Education

Outreach Program and Psychoeducational Workshop Request Form

Please provide the following information so that we may process your request. (All programs must be submitted three weeks prior to the date of the intended program.)

All fields are required.

Today's Date:

Requestor's Name:

Class/Organization:

Requestor's Position:

Telephone:

Email Address:

Brief Description of Workshop or Topic Requested:

Reason for Request/Perceived Need:

Preferred Dates / Times (You may list three options. If you have no preference, leave blank):

option 1:

option 2:

option 3:

Time Allotted for Program:

Number of Participants Expected:

How will the program be advertised?

Room / Building where the program will be held:

Please provide any additional information that will help us facilitate your request:

Counseling and Psychological Services Division of Student Affairs

Outreach & Education

Outreach Program and Psychoeducational Workshop Request Form