Outreach Request Form

Step 1Complete the Request Form

Step 2Confirm Request Information

Step 3Finished

Complete the Request Form

Please submit your request 2 weeks in advance of the event. While every effort will be made to fulfill outreach requests, The Baylor Counseling Center cannot ensure that every request can be accommodated.

Contact Information

First Name

Last Name

Organization

Position

Phone Number (include area code)

Email Address

Programming Information

Type of Outreach Programming

Event Information

Name of Event

Preferred Event Date

Preferred Event Time

Alternate Event Date

Alternate Event Time

Event Length

Event Location

Target Audience

Number of Attendees

Request for a Specific Staff Member

Additional Notes