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

Advisor of Organization, if applicable

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

Will A/V setup (computer and projector) be available to show slides

Event Format

Target Audience

Anticipated Number of Attendees

How will you be tracking/ensuring attendees

What other departments or organizations could you invite to join or partner with

Request for a Specific Staff Member

Additional Notes