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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.

 

 Today's Date:  Select date 

 

 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