Counseling Center

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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CounselingCenteruse only

Request received by : _______________________________________________________________

Staff presenter(s) : _________________________________________________________________

Program Date:_______________________ Attendance: _____________________________

Actual program topic : ______________________________________________________________

Titanium confirmation completed _____