Counseling Center

Counseling Center Program Request Form

Here at the Counseling Center, part of our mission is to raise awareness and help students learn about psychosocial and mental health issues. We're happy to offer programming on a wide variety of topics (for some examples, see the drop-down menu in the form below).

If you'd like to invite us to speak or facilitate with your group, partner with us to offer programming, or get support and resources to lead your own program, please fill out the request form below. We typically need at least two weeks to fit programs into our schedules, so please think ahead. We look forward to working with you!

Presentation Topic
Presentation for:	Class Student Organization Residence Hall Other: Please explain
Class/Organization/Hall Name
Estimated Number of Participants
What would you like the participants to get from this program?
Presentation Date: 2-weeks notice required	FIRST CHOICE: SECOND CHOICE:
Presentation Time	TO
Presentation Location
Please note: The Counseling Center will attempt to supply a speaker/facilitator and/or other resources to meet your request. However, we cannot guarantee that we will be available for every program.
Contact Person
Contact Person's Phone
Contact Person's e-mail (full e-mail address required)
Additional Comments
A member of the Counseling Center staff will contact you to respond to your request. This may take a few days, depending upon how quickly we can identify available staff. If you have not heard from us within 5 business days, please call the Counseling Center at 419-372-2081 and ask to speak with a member of the Community Based Interventions Committee.

Hours: Monday - Friday 8-5
104 College Park ~ 419-372-2081 FAX: 419-372-9535

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