. 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: 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. ☐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 Training 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 stigma) ☐ 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?