Presentation Request

Due to our clinical workload, we ask that you turn in your presentation request no later than the Monday 8:00 AM, two weeks before the event. This will increase the likelihood that we can meet your presentation request.

Topic:
Requested date of presentation:
Requested starting time of presentation:
Second choice of date:
Second choice of time:
Requested length of presentation:
Name of class/group:
Number expected to attend: (need at least 10 participants)
Location:
Person making request:
Title/responsibility:
Office phone:
Home phone:
E-mail address:
Best time/way to contact you:
Briefly describe the purpose of the presentation:
Briefly describe how this presentation will be advertised:
Other pertinent information:

Counseling and Psychological Services

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Presentation Request