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: