Habif Health and Wellness Center and Center for Counseling and Psychological Services Outreach Form

Last Name:

First Name:

Email Address:

Phone:

Department or Group Affiliation:

Topic Requested:

Overview of Habif and/or Counseling and Psychological Services

Self Care and Managing Stress

Body Image/Healthy Eating

Healthy Relationships

Emotional Well Being

Suicide Prevention/Assisting Students in Distress

Meditation/Mindfulness

Imposter Syndrome/Perfectionism

OtherOther

Anticipated Date:

Anticipated Time:

Length of Outreach Program Desired:

45 minutes

1 hour

1 hour +

Location of Outreach Presentation Desired:

Who is the intended audience for this Outreach Presentation?

Estimated size of audience/participants:

Technology Available at Location of Outreach Presentation:

Internet Connection

Computer

Video Display

Audio System or Amplification

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