If you would like the GSU Counseling Center to present an outreach program, please complete the form below and then submit. Upon receipt of this request, a Counseling Center representative will contact you to discuss the details of your request. Please provide the Counseling Center at least THREE WEEKS notice before an outreach event. Thank you!

 

Name: *

 
 

Email: *

 
 

Phone: *

 
 

Department: *

 
 

Role on Campus: *

 
     
 

Anticipated Date
(allow at least two weeks): *

 
 

Location of Outreach Program: *

 
 

Preferred Time: *

 
 

Length of Outreach Program: *

 
     
 

Requested Topic: *

 
     
 

Estimated Number of People Expected: *

 
 

Audio/ Visual Equipment Available
in Room?: *

 
     
 

Special Accommodations Needed: