Request a Presentation - Counseling Services - University of Utah Counseling Center

For presentation and outreach requests please complete the following form.

***Due to a high demand for services, we ask that you submit a request at least 3 weeks in advance. ***

For further information, please contact Catherine Riney.

Outreach Program & Psycho-Educational Workshop Request

Contact Information

First Name

Last Name

Class or Organization

Position

If other position or title, please specify

Phone Number

Email Address

Presentation/Workshop Information

Presentation/Workshop Topic

Reason for Request

Presentation/Workshop Goals

Preferred Dates and Times

Please indicate the dates and times you would like the educational presentation or consultation. We will make every effort to accommodate your first choice.

First Choice Date

MM/DD/YYYY

First Choice Time Range

HH:MM AM/PM

Second Choice Date

MM/DD/YYYY

Second Choice Time Range

HH:MM AM/PM

Third Choice Date

MM/DD/YYYY

Third Choice Time Range

HH:MM AM/PM

Number of participants expected

How will the program be advertised?

Building and Room Number

Additional Information

University Counseling Center

Student Affairs