CAPS Community Intervention Request
CAPS counselors are available to educate the campus community on mental health needs and available support services, as well as respond to events that impact the university and its students.
Name:
*
First Name
Last Name
E-mail
*
Phone Number
*
Affiliation to SIU:
Student
Staff/Faculty
Not Affiliated
Preferred Date of Intervention:
*
-
Month
-
Day
Year
Date
Preferred Time of Intervention:
*
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 Intervention:
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 Intervention Time:
Example: 30 minutes, 45 minutes, 60 minutes etc.
Location of Intervention:
Please include the name of the building, department, and room number.
Please describe the nature of the intervention you are requesting:
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
Other
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: