Outreach Services Request

Outreach Services Request

Complete this form to request or express interest in mental health talks, trainings, or groups from the Nick Finnegan Counseling Center.
Organization Information
Organization Type
Organization Name
Is your school a Title I school?
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Contact Person
Name

First NameLast Name
Role
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Type of Service Requested
School-Based Services

Other
Services for Non-profit/Religious Organizations

Other
Services for Corporations

Other
Services for Individuals

Other
Audience Details
Please describe the target audience (e.g., parents of 5th graders; young professionals)
Approximate Number of Participants
Topic Selection

Please view our menu for a list of potential topics. These topics can be designed to target any population - serving all ages and stages. We are passionate about developing programs that are tailor made to address each particular partners’ needs so please let us know if you have a specific request so that we can make sure we have the right talk for you!
General Topics

Other Topic
Parenting Topics

Other
Teacher Topics

Other
Corporate Talk Options

Other
Specific Concerns or Goals
Preferred Date/Time

MonthDayYear
Date
Hour MinutesAM/PM Option
Alternative Date/Time

MonthDayYear
Date
Hour MinutesAM/PM Option
Format
Group Topic Selection
Group Topic

Other
Grade Level(s) or Age(s)
Preferred Meeting Day/Time (e.g., Wednesdays at 12PM)
Preferred Start Date

MonthDayYear
Date
Additional Notes
Should be Empty:

Outreach Services Request

Organization Information

Contact Person

Type of Service Requested

Audience Details

Topic Selection

Group Topic Selection

Additional Notes