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Mental Health Outreach Program
Request Form
Please complete and submit the below form to LeAnna Rice at lrice@binghamton.edu two weeks before your
program. If it is less than two weeks, we will do our best to accommodate your request, but please note that we may
have to complete your request at a later date. Once your request is submitted, it will be reviewed within 2 business
days. You will receive an e-mail confirming your program and a presenter, or an e-mail asking for further clarification or
an alternate date if the date is unavailable by any of our staff. If you wish, you may include alternate dates below. We
are excited about partnering with you to help keep our campus healthy and well!
Date of Request:
Contact Person:
Name of Organization, Group, or Class:
E-mail:
Date of Program:
Start Time of Program:
Length of Program:
Location of Program:
Program Information
Technology Available (Please all that apply) ☐ Computer/laptop ☐ Projector ☐ Sound System/Speakers ☐ Internet
Access
Type of event (Please check one) ☐Tabling ☐ Workshop (interactive) ☐ Other _________________________
Projected Number of Participants:
Target Audience (freshmen, athletes, faculty/staff etc.):
Type of Program/Outreach
Please check all that apply.
If you want to combine certain topics, please choose the topics you’d like to combine and specify the vision of the
program in the box below, and we’ll do our best to accommodate your request.
☐ Balanced Eating: Basics of
☐Stress Management (overview)
☐ Other (please specify)
Nutrition & Eating for Health
_________________________
☐ Challenging Negative Thinking for
☐
Nutrition
&
Bingeing:
How
to
Stress Reduction
Develop a Healthy Relationship
☐ Perfectionism
with Food
☐ Depression
☐ Handling Difficult Emotions
☐ General Counseling Information
☐ Body Image/Self-Acceptance
(Topics generally covered in this session are:
☐ Grief and Loss
counseling center services, college students and
☐ How to be Happy
mental health issues, identifying distressed/at
risk students, referrals and mental health
☐ Assertiveness/Confrontation
Training
stigma)
☐ Social/Communication Skills
☐ Healthy Relationships
☐ Grief and Loss
☐Handling Break Ups
☐ Anxiety
☐ Meditation and Mindfulness
Edited October 2014
☐ Diversity/Cultural Issues in
Mental Health (Please specify)
_________________________
_________________________
☐ Adjusting to College
☐ Suicide Prevention
.
What are the goals/expectations for this program for the participants?
Any additional information that will be helpful for the presenter?
Edited October 2014