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Outreach Request Form

Please complete the following outreach request form and click "Submit Form" below at least 3-weeks before the requested outreach date so that we may process your request.

Please note that while we try to meet all outreach requests, participation is not guaranteed or even possible at times, given the increasing demands for Counseling Center services. Please contact our office at 904-620-2602 with any questions.

 

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Your Name and Title

 

Your Phone Contact

 

Your Email

 

Name of your Department/Class/Organization

 

Description of the Event (including involvement you are requesting from us):


 

 

Date and Time of the Event

 

Counseling Center Times of Involvement (ONLY IF DIFFERENT FROM ABOVE): 

 

Location of the Event (building/room number, etc.)

 

Number of Participants/Attendees Expected

 

Goals or Purpose of the the Event


 

 

Other/Additional Information