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Counseling and Psychological Services

Workshop Request Form

Program Requests

Programs are typically conducted Monday - Thursday and no later than 8 pm. All program requests need to be submitted two weeks prior to the date of the intended program.

Please provide the following information so that we may process your request and find a presenter for you. When you have completed this form, please press the Submit button at the end of the page. Ben Salazar, Psychology Intern, or Marty Green, Coordinator of Outreach and Consultation Services, will get back with you within one week.

If for some reason, you have not heard back from Ben or Marty within 7 days from the date your request, please call Ben or Marty at (765) 494-6995 or email Ben Salazar or Marty Green. If you have questions or comments feel free to contact our office.

Fields designated with an asterisk (*) are required. Submissions with blank required fields will not properly transmit to CAPS.

Please complete a separate form for each program topic requested.

Contact Information

Today's Date

First and Last Name (*)

Phone Number (*)

Email Address (*)

Class or Organization Name (*)

Contact me via:

Program Information

Brief Description of Program Topic (*)

Requested Dates/Times (*)

Programs are only held Monday through
Thursday between 8:00am and 8:00pm.

Two week notice is required.

     
    
    

Location Where Program Will Be Held (*)

Desired Length of Program:

Number of People Expected at Program:

Marketing Information

How will the program be advertised?  (Check all that apply)

Flyer
Table Tents
Word of Mouth
Email
Other (Please identify) 

Are you willing to be involved in the planning and/or implementation of the program?

Yes No

Additional Information

Please provide any additional information that will help us facilitate your request: 

Submit or Reset Form

After pressing the Submit button below your information will be sent to the Coordinator of Outreach and Consultation in the form of an email. Dr. Don will contact you within one week of your submitting the request.


Thank you very much for completing this on-line outreach request.