Program Request: UNCW Counseling Center

If you would like the UNCW Counseling Center to present a program, please complete this form, print it, and return it to the Counseling Center, Box #5937 or email to westside2079@uncw.edu.   We will make every effort to fulfill your request. 

Today’s Date:  ______________________ Requested by:  _________________________________

Phone Number:  _____________________    email:  _____________________________

Student _____           Faculty  _____          Staff  _____

If faculty/staff, department:_________________________________________________________

Audience (and estimated #: minimum of 10)  _________________________________________

Special Accommodations: ________________________________________________________

Requested Topic: _______________________________________________________________

______________________________________________________________________________

Preferred date (allow at least 2 weeks):  ______________       Preferred time:  ______________

Length:      45 min     1 hr          1.25 hrs                  1.5 hrs        Other (specify):__________________

Location (building/room):  __________________________________________________________

Audio/visual equipment available in room? (eg. Smart classroom)______________________

If audio/visual fee is required, who will pay the fee?______________________________

Upon receipt of this request, a Counseling Center representative will contact you to discuss the details of your request.  Thank you!

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Counseling Center use only

Request received by : _______________________________________________________________

Staff presenter(s) : _________________________________________________________________

Program Date:_______________________          Attendance:  _____________________________

Actual program topic :  ______________________________________________________________

Titanium confirmation completed _____

 


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