Program Request Form

Mental Health Outreach Program
Request Form
Please complete and submit the below form to LeAnna Rice at [email protected] 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:
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
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.
☐Stress Management (overview)
☐ Meditation and Mindfulness
☐ Challenging Negative Thinking for
Stress Reduction
☐ Handling Difficult Emotions
☐ Perfectionism
☐ Depression
☐ General Counseling Information
☐ Body Image/Self-Acceptance
☐ Grief and Loss
☐ How to be Happy
(Topics generally covered in this session are:
☐ Assertiveness/Confrontation
counseling center services, college students and
☐ Social/Communication Skills
mental health issues, identifying distressed/at
☐ Diversity/Cultural Issues in
Mental Health (Please specify)
risk students, referrals and mental health
☐ Healthy Relationships
☐ Grief and Loss
☐Handling Break Ups
☐ Anxiety
☐ Adjusting to College
☐ Suicide Prevention
☐ Other (please specify)
What are the goals/expectations for this program for the participants?
Any additional information that will be helpful for the presenter?