CAPS Community Intervention Request
Counseling and Psychological Services (CAPS) is a department of Student Health Services
Name:
*
First Name
Last Name
E-mail
*
Phone Number
*
Affiliation to SIU:
Student
Staff/Faculty
Not Affiliated
Preferred Date of Presentation:
*
-
Month
-
Day
Year
Date
Preferred Time of Presentation:
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Alternative Date:
-
Month
-
Day
Year
Date
Alternative Time of Presentation:
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Length of Presentation Time:
Example: 30 minutes, 45 minutes, 60 minutes etc.
Location of Presentation:
Please include the name of the building, department, and room number.
Please describe the topic(s) you would like presented upon:
Audience Description:
Undergraduate
Graduate Students
Staff/Faculty
Community
Expected Number of Participants:
10 - 20 people
21 - 30 people
31 - 50 people
51 - 75 people
More than 100 people
Is there audio/visual equipment available at the location of the presentation?
*
Yes
No
Limited
I don't know
If yes, please describe what audio/visual equipment is available for the presenter at your location:
Tell us anything else we need to know:
Submit
Should be Empty: