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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