Outreach 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 Name First Name Last Name Organization Position Advisor of Organization if applicable Phone Number Email Address Program Information Type of Outreach Program - Select - Accessing BUCC Services Building Healthy Relationships Helping Students in Distress Mental Health First Aid Mindfully Managing Stress QPR Tabling Event Thriving Just Not Surviving Other Other Type of Outreach Program 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 - Select - Yes No Possible to look into arrangements Event Format - Select - In Person Virtual (Zoom) when available Open to either option Target Audience Anticipated Number of Attendees How will you track/ensure attendees What other departments or organizations could you invite to join or partner with How do you plan to advertise this event/program Word of mouth Email Social Media Flyers/Sinage Other Other Advertising Plan Request for a specific staff member Additional Notes
