Outreach Request Form - Student Counseling Center

Community Intervention /Outreach

Please complete this form to request a program from the SCC. NOTE: The staff at the counseling center will not be able to fulfill requests for interviews for class assignments/papers/projects.

Your Name*
Email Address*
Anticipated Audience*
- Faculty
- Undergraduate Students
- Graduate Students
- Parents
- Community
- Other (explain in "other Information")
Name of group/organization/class
Topic Requested
Proposed Date of Event*
MM slash DD slash YYYY
Time of Event*

: Hours

Minutes

AM/PM
Number expected
Duration of event? (15, 30, 60, 90 minutes, etc)
Other Information. Please include whether this is an IN PERSON or ZOOM request:
Phone
This field is for validation purposes and should be left unchanged.