Counseling and Consultation Services Outreach Request From
To request the assistance of CCS staff for an outreach, training program, or interview, please complete the form below. Please provide a minimum of 3 weeks' notice when requesting your event to allow us time to prepare and identify staff who might be available. Some events may require more than 3 weeks' notice. All requests will be reviewed by the Outreach Coordinator, who will follow up with you. Approval of requests is dependent on factors such as scheduling, availability of staff, planning time needed, and the type of request submitted. If you have any questions or difficulties completing this form, please contact the CCS office at 317-955-6150 or email CCS@marian.edu
Select Status
Student
Faculty
Staff
Name:
*
First Name
Last Name
Marian Email:
*
example@example.com
Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Department or Group Facilitating:
Event Date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Start Time
Hour Minutes
AM
PM
AM/PM Option
End Time
Hour Minutes
AM
PM
AM/PM Option
Back
Next
Event Topic
Anxiety
Bystander Training
Depression
Eating Disorders
Mental Wellness Toolkit (staff/faculty)
Mindfulness
Multiculturalism or Diversity
Referring Students to the Student Counseling Center (staff/faulty)
Relationships
Stress Managment
Student Counseling Center Services
Substance Use
Suicide Prevention
Time Prevention
Trauma
Other
If other, please specify:
Event Location (Building number, room number in building, St. Joe's, Ancilla, etc.):
*
Approximate Number of Participants:
Audience (Select all that apply):
Undergraduate Students
Graduate Students
Medical Students
Faculty
Staff
Please provide a brief description of the planned event, including the event format (panel, workshop, speaker, etc.):
SPECIFIC areas you would like addressed during the presentation (ex. " During the presentation on stress management, we would like the sections specifically addressing burnout and procrastination"):
Purpose/Reason for Request (e.g. Class assignment, group requirement, interest in topic):
I understand this request must be submitted at least three weeks in advance of the event.
*
I understand
I understand I may be contacted by the presenter for more information regarding class demographics, major, etc.
*
I understand
Submit
Should be Empty: