Program Request: UNCW Counseling Center
If you would like the UNCW Counseling Center to present a program, please complete this form, print it,
and return it to the Counseling Center, Box #5937 or email to westside2079@uncw.edu. We will make
every effort to fulfill your request.
Today’s Date: _______________________________ Requested by:_____________________________
Phone Number: ________________________ Email address: _________________________________
Student ______
Faculty ______
Staff _____
If faculty/staff, department: _____________________________________________________________
Audience (and estimated #: minimum of 10) ________________________________________________
Special Accommodations Needed: ________________________________________________________
Requested Topic: ______________________________________________________________________
_____________________________________________________________________________________
Preferred date of presentation (please allow at least two weeks): ___________ Preferred time: ______
Requested Length: 45 min
1 hr
1.25 hrs
1.5 hrs
Other (specify): _____________
Location (building/room): _______________________________________________________________
Audio/visual equipment available in room? (e.g. Smart classroom) _______________________________
Is an audio/visual equipment fee required and are you able to pay it? ____________________________
Upon receipt of this request, a Counseling Center representative will contact you to discuss the details of
your request. Thank you!
Counseling Center use only
Request received by: ___________________________________________________________________
Staff presenter(s): _____________________________________________________________________
Program Date: ___________________________ Attendance: _________________________________
Actual program topic: __________________________________________________________________
Titanium confirmation completed _____________