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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