Outreach Request Form

If you would like to request an outreach program or presentation, please complete the following form.

Please note: We request a minimum of 3 weeks advanced notice and while we will do our best to meet your outreach request, we cannot guarantee availability.

Name*
First Last
Email*
Phone*
Please describe the program you are requesting (topic, format, duration, etc.)*
What are your goals for this program?*
Who is the audience (e.g. name of class, residence hall, organization, etc.)? Please include number of participants.*
Location*
Please provide several potential dates and times (note: we request a minimum of 3 weeks advanced notice)*

Counseling Center

217 Roosevelt Hall / 401.874.2288

Outreach Request Form