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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