Counseling Center Outreach / Program Request

If you would like the IWU Counseling & Consultation Services to present an outreach program, please complete this form. We will make every effort to fulfill your request. We appreciate a 2 week notice for requests as our schedules can fill up quickly. You will receive an email confirmation within seven business days. If you don't hear from us, please contact us at 309-556-3052.

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1. Today's Date:

Date

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2. Person making this request:

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3. Organization making this request:

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4. Best Contact E-Mail Address:

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5. Telephone Number:

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6. Relationship to University:

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7. If you are faculty or staff, please let us know your department:

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8. Please identify audience and the estimated number of participants:

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9. Special Accommodations Needed:

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10. Requested Topic of Presentation:

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11. Other Details about the Requested Presentation:

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12. What is your preferred date for this presentation?

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13. What is your preferred time for this presentation?

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14. What is your preferred length for this Presentation?:

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15. Location (Building & Room):

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16. Is Audio/Visual equipment and Internet available in the room?

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17. Is there anything else you would like to let us know about your request?

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